UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


56iy 

GENERAL   SURGICAL 

PATHOLOGY  AND  THERAPEUTICS, 

A   TEXT-BOOK  FOR  STUDENTS  AND  PHYSICIANS. 


BY 

Dk.  THEODOR   BILLROTH, 

PROFESSOR  OP  SUKGERT  IN  VIENNA. 
WITH    ADDITIONS   BY 

De.  ALEXANDER  YON  WINIWARTER, 

PROFESSOR  OF   SURGERT  IN  LUTTICH. 


TRANSLATEP    FROM    TTIE   FOURTH   GERMAN   EDITION,   WITH   THE  SPECIAL    PERMISSION   OF   THE 
AUTHOR,  AND  REVISED  FROM  THE  TENTH  EDITION,  BY 

CHARLES  E.  HACKLEY,  A.  M.,  M.  D., 

PHYSICIAN  TO  THE  NEW  YORK  AND  TRINITY  HOSPITALS,  MEMBER  OF  THE  NEW  YORK  COUNTY 

MEDICAIi  SOCIETY,  ETC. 


NEW    YORK: 
D.    APPLETON    AND    COMPANY, 

1,    3,    AND    5    BONB    STREET. 

1889. 


Entebed,  according  to  Act  of  Congress,  in  the  year  1871,  by  Charles  E.  Hackley,  in  the 
Oflacc  of  the  Librarian  of  Congress,  at  Washington. 


Entered,  according  to  Act  of  Congress,  in  the  year  1878,  by  Chables  E.  Hackley,  in  the 
Office  of  the  Librarian  of  Congress,  at  Washington. 


Enteeed,  according  to  Act  of  Congress,  in  the  year  1879,  by  Charles  E.  Hackley,  in  the 
Office  of  the  Librarian  of  Congress,  at  Washington. 


Enteeed,  according  to  Act  of  Congress,  in  the  year  1882,  by  Charles  E.  Hackley,  in  th« 
Office  of  the  Librarian  of  Congress,  at  Washington. 


TRANSLATOR'S  PREFACE. 


As  will  be  seen  bj  the  author's  preface,  Prof.  Billroth,  with 
the  ninth  edition,  turns  over  his  work  to  a  successor  chosen  by 
himself. 

While  we  cannot  help  regretting  his  leave-taking  from  active 
literary  effort,  we  must  admire  the  strong  good  sense  of  a  man 
in  being  able  to  decide  on  leaving  a  work  while  in  full,  vigorous 
bloom ;  while  the  leaves  of  his  book  are  almost  as  fresh  as  when 
first  published.  Prof.  "Winiwarter,  who  is  the  successor,  is  per- 
haps best  known,  in  this  country  at  least,  by  his  contribution  to 
the  knowledge  of  malignant  sarcoma.  The  additions  to  the  book 
have  been  quite  numerous ;  and  they,  as  well  as  additions  by  the 
translator,  are  enclosed  in  brackets  [  ]. 

In  the  present  English  edition,  the  articles  which  were  in  an 
appendix  in  the  last  edition,  as  well  as  various  new  matter,  have 
been  incorporated  in  the  text  or  added  on  the  ends  of  the  appro- 
priate chapters.  It  will  be  noticed  that  two  German  editions  have 
appeared  since  Prof.  Billroth's  valedictory,  so  that  his  successor 
has  had  an  opportunity  of  going  very  thoroughly  over  the  work, 
and  making  all  the  changes  he  thought  advisable.  It  is  believed 
that  the  present  edition  represents  the  existing  state  of  knowledge ' 
in  pathology. 

s:,N  CHARLES  E.  HACKLEY,  M.  D. 

New  York,  Novemher,  1882. 

f  6242G6 


PREFACE  TO  THE  NINTH  GERMAN  EDITION. 


When  ray  publisliers  recently  asked  me  to  prepare  a  new 
edition  of  this  book,  after  much  reflection  I  concluded  that  I 
should  not  be  able  to  do  so  with  as  much  pleasure  as  formerly. 
The  practice  of  my  profession,  social  duties,  and  my  work  as 
teacher,  have  so  absorbed  my  time  during  the  past  ten  years  that 
I  have  not  followed  the  advance  of  medical  science  as  closely  as 
one  should  who  was  to  present  the  results  of  recent  workers  to  a 
new  generation  of  students.  And,  trying  as  it  was,  I  concluded 
not  to  attempt  the  work  of  revision  myself.  To  my  great  pleas- 
ure, Prof.  Alexander  von  Winiwarter  undertook  the  task,  and  has 
so  successfully  accomplished  it  that  the  book  will  again  for  a 
time  serve  as  a  guide  to  students  and  practitioners  in  their  studies 
of  genera]  surgical  pathology  and  therapeutics. 

This  task  was  the  more  trying  because  this  book  was  so  pe- 
culiarly my  own  work.  Prof.  Winiwarter  has  piously  retained 
my  model ;  but  I  wish  that  in  future  editions  he  may  conform 
more  and  more  to  his  own  views,  and  those  of  the  present  and 
coming  surgical  generations  ;  this  is  the  only  plan  that  will  ensure 
its  prolonged  life. 

With  this  preface  I  bid  farewell,  as  a  surgical  writer,  to  read- 
ers who  have  so  long  cheered  me  by  their  sympathy  and  encour- 
agement. I  may  say  with  pride  that  success  has  crowned  my  at- 
tempts to  excite  pleasure  and  effort  in  many  young  men  studying 
the  noble  art  and  science  of  surgery. 

Many  thanks  to  all  who  have  aided  me  in  these  attempts. 

TH.  BILLROTH. 

Vienna,  January,  1880. 


COKTEKTS. 


LECTURE  1. 


INTRODUCTION, 


Relation  of  Surgery  to  Internal  Medicine. — Necessity  of  the  Practising  Physician 
being  acquainted  with  both. — Historical  Remarks. — Nature  of  the  Study  of  Sur- 
gery in  the  Gennan  High-school, page  1 


CHAPTER  I. 

SIMPLE  IS^CISED  WOUNDS  OF  TEE  SOFT  PARTS. 

LECTURE  II. 

Mode  of  Origin  and  Appearance  of  thede  Wounds. — Various  Fonns  of  Incised  Wounds. 
— Appearance  during  and  immediately  after  their  Occurrence. — Pain,  Bleeding. — 
Varieties  of  Hsemorrliage ;  Arterial,  Venous. — Entrance  of  Air  through  Wounded 
Veins. — Parenchymatous  HaBmorrhage. — Hsemorrhagio  Diathesis. — Haemorrhage 
from  the  Pharynx  and  Rectum.  —  Constitutional  Effects  of  Severe  Hsemor- 
rhage, ....    p.  17 

LECTURE  III. 

■treatment  of  Haemorrhage. — 1.  Ligature  and  Mediate  Ligature  of  Arteries. — 2.  Com- 
pression by  the  Finger ;  Choice  of  the  Point  for  Compression  of  the  Larger  Arte- 
ries.— Tourniquet. — Acupressure.  —  Bandaging. — Tampon. — 3.  Styptics.  —  General 
Treatment  of  Sudden  Ansemia. — Transfusion,  .  ....    p.  26 

LECTURE  IV. 

Japing  of  the  Wound. — Union  by  Plaster. — Suture  ;  Internipted  Suture ;  Twisted  Su- 
ture.— External  Changes  perceptible  in  the  United  Wound. — Healing  by  First  In- 
tention,   .    p.  43 

LECTURE  V. 

i'he  more  Minute  Changes  in  Healing  by  the  First  Intention. — Dilatation  of  Vessels  in 
the  Vicinity  of  the  Wound. — Fluxion. — Different  Views  regarding  the  Causes  of 
Fluxion, ....        p.  52 

LECTURE  VI. 
Changes  in  the  Tissue  during  Healing  by  the  First  Intention. — Plastic  Infiltration.— 
Inflammatory  New  Formation. — Retrogression  to  the  Cicatrix. — Anatomical  Evj- 


vi  CONTENTS. 

dences  of  Inflammation. — Conditions  under  which  Healing  by  First  Intention  does 
not  occur.— Union  of  Parts  that  have  been  completely  separated,     .        .    page  Gl 

LECTUKE  VII. 

Changes  perceptible  to  the  Naked  Eye  in  "Wounds  with  Loss  of  Substance.— Finer  Pro- 
cesses in  Healing  with  Granulation  and  Suppuration.— Pus.— Cicatrization.— Obser- 
vations on  "Inflammation." — Demonstration  of  Preparations  illustrative  of  the 
Healing  of  Wounds, P- '^5 

LECTUEE  VIII. 

General  Reaction  after  Injury.— Surgical  Fever.— Theories  of  the  Fever. -Prognosis.— 
Treatment  of  Simple  Wounds  and  of  Wounded  Persons.— Burrowing  Wounds.— 
Open  Treatment  of  Wounds.— Zw^er's  Method. — Coccobacteria  Septica,       .    p.  94 

LECTUEE  IX. 

Combination  of  Healing  by  First  and  Second  Intention.— Union  of  Granulation  Surfaces. 

Healing  under  a  Scab. — Granulation  Diseases. — The  Cicatrix  in  Various  Tissues  ;  in 

Muscle;  in  Nerve;  its  Knobby  Proliferation;  in  Vessels.— Organization  of  the 

Thrombus. — Arterial  Collateral  Circulation, p.  107 


CHAPTER  II. 

SOME  PECULIARITIES  OF  PUNCTURED   WOUNDS. 

LECTUEE  X. 

As  a  Rule,  Punctured  Wounds  heal  quickly  by  First  Intention. — Needle  Punctures  ; 
Needles  remaining  in  the  Body,  their  Extraction. — Punctured  Wounds  of  the  Nerves. 
— Punctured  Wounds  of  the  Arteries :  Aneurysma  Traumaticum,  Varicosum,  Varix 
Aneurysmaticus. — Punctured  Wounds  of  the  Veins,  Venesection,      .        .    p.  138 


CHAPTER  III. 

CONTUSIONS  OF  THE  SOFT  PARTS  WITHOUT  WOUNDS. 
LECTUEE  XI. 

Causes  of  Contusions. — Nervous  Concussion. — Subcutaneous  Rupture  of  Vessels. — Rup 
ture  of  Arteries. — SuggUlations. — Ecchymoses. — Reabsorption. — Termination  in 
Fibrous  Tumors,  in  Cysts,  in  Suppuration,  and  Putrefaction. — Treatment,      p.  149 


CHAPTER  IV. 

CONTUSED  AND  LACERATED   WOUNDS  OF  THE  SOFT  PARTS. 
LECTUEE  XII. 

Mode  of  Occurrence  of  these  Wounds ;  their  Appearance. — Slight  Haemorrhage  in  Con- 
tused Wounds. — Early  Secondary  Haemorrhages. — Gangrene  of  the  Edges  of  the 
Wound. — Influences  that  effect  the  Slower  or  more  Rapid  Detachment  of  the  Dead 
Tissue. — Indications  for  Primary  Amputation. — Local  Complications  in  Contused 
Wounds;  Decomposition,  Putrefaction,  Septic  Inflammations. — Contusion  of  Ar- 
teries ;  Late  Secondary  Haemorrhages, p.  16-3 


CONTENTS. 


LECTUEE  XIII. 


Progressive  Suppuration  starting  from  Contused  "Wounds. — Secondary  Inflammations 
of  tlie  Wound:  their  Causes;  Local  Infection. — Febrile  Eeaction  in  Contused 
Wounds :  Secondary  Fever ;  Suppurative  Fever ;  Chill ;  their  Causes. — Treatment 
of  Contused  Wounds :  Immersion,  Ice-tladders,  Irrigation ;  Criticism  of  these 
Methods, — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open  Treat- 
ment of  Wounds. — Prophylaxis  against  Secondary  Inflammations. — ^Internal  Treat- 
ment of  those  severely  Wounded. — Quinine. — Opium. — Lacerated  Wounds :  Sub- 
cutaneous Eupture  of  Muscles  and  Tendons ;  Tearing  out  of  Muscles  and  Tendons ; 
Tearing  out  of  Pieces  of  a  Limb, page  177 


CHAPTER  V. 

SIMPLE  FB  AC  TUBES   OF  BONES 

LECTUEE  XIV. 

Causes,  Different  Varieties  of  Fractures. — Symptoms,  Diagnosis. — Course  and  External 
Symptoms. — Anatomy  of  Healing,  Formation  of  Callus. — Source  of  the  Inflamma- 
toiy  Osseous  New  Formation. — Histology, p.  195 


LECTUEE  XV. 

Treatment  of  Simple  Fractures. — Seduction. — Time  for  applying  the  Dressing,  its 
Choice. — Plaster  of  Paris  and  Starch  Dressings,  Splints,  Permanent  Extension. — 
Ketaining  the  Limb  in  Position. — Indications  for  removing  the  Dressings,      p.  211 


CHAPTER  VI. 

OPEN  FBACTUBE3  AND  8UPPUBATI0N  OF  BONE. 

Difference  between  Subcutaneous  and  Open  Fractures  in  regard  to  Prognosis. — Vari- 
eties of  Cases. — Indications  for  Primary  Amputation. — Secondary  Amputation. — 
Course  of  the  Cure. — Suppuration  of  Bone. — Necrosis  of  the  Ends  of  Frag- 
ments,       p.  222 

LECTURE  XVI. 

Development  of  Osseous  Granulations. — Histology. — Detachment  of  the  Sequestrum. — 
Histology. — Osseous  New  Formation  around  the  Detached  Sequestrum. — Callus  in 
Suppurating  Fractures. — Suppurative  Periostitis  and  Osteomyelitis. — General  Con- 
dition.— Fever. — Treatment;  Fenestrated,  Closed,  Split  Dressings. — Antiplilogis- 
tic  Eemedies.  —  Immersion. — Listeria  Method.  —  Rules  about  Bone-splinters. — 
After-Treatment, .p.  223 

APPENDIX  TO  CHAPTERS  V.  AND   YI. 

LECTURE  XVIL 

1.  Retarded  Formation  of  Callus  and  Development  of  Pseudarthrosis. — Causes  often 
unknown.  —  Local  Causes.  —  Constitutional  Causes. — Anatomical  Conditions. — 
Treatment:  internal,  operative;  Criticism  of  Methods.  2.  Obliquely-united 
Fractures;  Rebreaking,  Bloody  Operations.  — Abnormal  Development  of  Cal- 
lus,     p.  241 


viii  CONTENTS. 

CHAPTER   VII. 

INJURIES    OF    THE   JOINTS. 

Contusion. — Distortion. — Massage. — Opening  of  the  Joint,  and  Acute  Traumatic  Ar- 
ticular Inflammation. — Variety  of  Course,  and  Kesults. — Treatment. — Anatomical 
Changes, page  249 

LECTURE  XVIII. 

Simple  Dislocations;  Traumatic,  Congenital,  Pathological  Luxations,  Subluxations. — 
Etiology. — Difficulties  in  Reduction,  Treatment;  Reduction,  After-Treatment. — 
Habitual  Luxations. — Old  Luxations,  Treatment.— Complicated  Luxations. — Con- 
genital Luxations, p.  260 

CHAPTER   VIII. 

G  UN8H0  T-W  OUN  DS. 

LECTURE  XIX. 

Historical  Remarks. — Injuries  from  Large  Missiles. — Various  Eorms  of  Bullet-Wounds. 
— Transportation  and  Care  of  the  Wounded  in  the  Field. — Treatment. — Compli- 
cated Gunshot-Fractures, p.  273 

CHAPTER   IX. 

BURNS   AND    FBOST-BITES. 

LECTURE  XX. 
1.  Burns:    Grade,  Extent,  Treatment.— Sunstroke.— Stroke  of  Lightning. — 2.  Frost- 
bites :  Grade. — General  Freezing,  Treatment. — Chilblains,         .        .        ,    p.  286 

CHAPTER   X. 

ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  TEE  SOFT  PARTS. 
LECTURE  XXI. 

General  Etiology  of  Acute  Inflammations. — Acute  Inflammation:  1.  Of  the  Cutis, 
a.  Erysipelatous  Inflammation ;  S,  Furuncle ;  c,  Carbuncle  (Anthrax),  Pustula  Ma- 
ligna. 2.  Of  the  Mucous  Membranes.  3.  Of  the  Cellular  Tissue,  Acute  Abscesses. 
4.  Of  the  Muscles.  5.  Of  the  Serous  Membranes,  Sheaths  of  the  Tendons,  and 
Subcutaneous  Mucous  Burste, p.  300 

CHAPTER    XI. 

ACVTE  INFLAMMATIONS  OF  THE  BONES,  PERIOSTEUM,  AND  JOINTS. 
LECTURE   XXII. 

Anatomy. — Acute  Periostitis  and  Osteomyelitis  of  the  Long  Bones :  Symptoms,  Ter- 
minations in  Resolution,  Suppuration,  Necrosis,  Prognosis,  Treatment. — Acute 
Ostitis  in  Spongy  Bones. — Multiple  Acute  Osteomyelitis. — Acute  Inflammations 
of  the  Joints. — Hydrops  Acutus ;  Symptoms,  Treatment. — Acute  Suppurative  In- 
flammations of  Joints :  Symptoms,  Course,  Treatment,  Anatomy. — Acute  Articular 
Rheumatism. — Arthritis. — Metastatic  Inflammations  of  Joints  (Gonorrhceal,  Py- 
emic, Puerperal), p.  324 

APPENDIX  TO   CHAPTERS  I.-XL 
Review.— General  Remarks  about  Acute  Inflammation, p.  844 


CONTENTS.  ix 

CHAPTER  XII. 

GANGRENE. 

LECTURE  XXI]  I. 
Dry,  Moist  Gangrene. — Immediate  Causes. — Process  of  Detachment. — Varieties  of  Gan- 
grene according  to  the  Kemote  Causes.— 1.  Loss  of  Vitality  of  tbe  Tissue  from 
Mechanical  or  Chemical  Causes. — 2.  Complete  Arrest  of  the  Afflux  and  Efflux  of 
Blood. — Incarceration. — Continued  Pressure. — Decubitus. — Great  Tension  of  the 
Tissue. — 3.  Complete  Arrest  of  the  Supply  of  Arterial  Blood. — Gangrena  Spon- 
tanea.— Gangrena  Senilis. — Ergotism. — i.  Noma. — Gangrene  in  Various  Blood- 
Diseases. — Treatment, page  353 


CHAPTER  XIII. 

ACCIDENTAL  TRAUMATIC  AND  INFLAMMATORY  DISEASES,  AND  POISONED 

WOUNDS. 

LECTURE  XXIV. 
I.  Local  Diseases  which  may  accompany  Wounds  and  Other  Points  of  Inflammation  : 
1.  Progressive  Purulent  and  Purulent  Putrid  DiflTuse  Inflammation  of  Cellular 
Tissue. — 2.  Hospital  Gangrene. — 3.  Traumatic  Erysipelas. — 4.  Lymphangitis,  p.  367 

LECTURE  XXV. 

5.  Phlebitis;  Thrombosis;  Embolism. — Causes  of  Venous  Thrombosis  ;  Various  Meta- 
morphoses of  the  Thrombus. — Embolism. — Red  Infarction,  Embolic  Metastatic 
Abscesses. — Treatment, p.  386 

LECTURE  XXVI. 
II. — General  Accidental  Diseases  which  may  accompany  Wounds  and  Local  Inflamma- 
tions.   1.  Traumatic  and  Inflammatory  Fever ;  2.  Septic  Fever  and  Septicaemia; 
3.  Suppurative  Fever  and  Pyaemia, p.  396 

LECTURE  XXVn. 

4.  Tetanus ;  5.  Delirium  Potato-um  Traumaticum ;  6.  Delirium  Nervosum  and  Mania. — 
Appendix  to  Chapter  XIII. — Poisoned  Wounds;  Insect-bites,  Snake-bites;  Infec- 
tion from  Dissecting  Wounds. — Glanders. — Carbuncle. — Diseases  from  Mouths 
and  Claws  of  Animals.— Hydrophobia, P-  423 


CHAPTER   XIV. 

CnnONIG  INFLAMMATION,  ESPECIALLY  OF  THE  SOFT  PARTS. 

LECTURE  XXVIII. 
Anatomy:   1.   Thickening,  Hypertrophy ;   2.   Hypersecretion;   3.   Suppuration,  Cold 
Abscesses,  Congestive  Abscesses,  Fistula,  Ulceration. — Results  of  Chronic  Inflam- 
mation.— General  Symptomatology. — Course, p.  444 

LECTURE  XXIX. 

General  Etiology  of  Chronic  Inflammation. — External  Continued  Irritation. — Causes  in 
the  Body. — Empirical  Idea  of  Diatheses  and  Dyscrasia;.— General  Symptomatology 
and  Treatment  of  Morbid  Diatheses  and  DyscrasioB.  1.  The  Lymphatic  Diathesis 
(Scrofula);  2.  Tuberculous  Dyscrasia  (Tuberculosis) ;  3.  The  Arthritic  Diathesis ; 
4.  The  Scorbutic  Dyscrasia ;  5.  Syphilitic  Dyscrasia,  .        .        .        .p.  451 


X  COXTENTS. 

LECTURE    XXX. 

Local  Treatment  of  ChroDic  Inflammation :  Eest,  Compression,  Moist  Warmtli,  Hy- 
dropathic Wraps,  Resorbents,  Antiplilogistics,  Derivatives,  Fontanels,  Setons, 
Moxae,  the  Hot  Iron, page  474 


CHAPTER  XV. 

ULCERS. 

LECTURE  XXXI. 
Anatomy. — External  Peculiarities  of  Ulcers ;  Form  and  Extent,  Base  and  Secretion, 
Edges,  Parts  around. — Local  Treatment  according  to  the  Local  Condition  of  the 
Ulcer ;  Fungous,  Callous,  Putrid,  Phagedenic,  Sinuous  Ulcers,  Etiology,  Contin- 
ued Irritation,  Venous  Congestion,  Dyscrasial  Causes,        .       .       .       .p.  48o 

CHAPTER  XVI. 

CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  OF  THE  BONE,  AND 

NECROSIS. 

LECTURE  XXXn. 
Chronic  Periostitis  and  Caries  Superficialis. — Symptoms. — Osteophytes. — Osteoplastic, 
Suppurative  Forms. — Anatomy  of  Caries. — Etiology. — Diagnosis. — Combination 
of  Various  Forms, p.  495 

LECTURE  XXXIII. 

Primary  Central,  Chronic  Ostitis,  or  Caries. — Symptoms. — Ostitis  Interna  Osteoplas- 
tica,  Suppurativa,  Fungosa. — Abscess  of  Bone. — Combinations. — Ostitis  with  Cas- 
eous Metamorphosis. — Tubercles  of  Bone. — Diagnosis  of  Caries. — Dislocation  of  the 
Bou«s  after  their  Partial  Destruction. — Congestion  Abscesses. — Etiology,     p.  505 

LECTURE  XXXIV. 

Process  of  Cure  in  Caries  and  Congestion  Abscesses, — Prognosis. — General  Health  in 
Chronic  Inflammations  of  the  Bone. — Secondary  Lymphatic  Enlargements. — 
Treatment  of  Caries  and  Congestion  Abscesses.  —  Resections  in  the  Conti- 
nuity,            p.  516 

LECTURE  XXXV. 
Necrosis. — Etiology. — Anatomical  Conditions  in  Total  and  Partial  Necrosis. — Symp- 
toms and  Diagnosis. — Treatment. — Sequestrotomy, p.  529 

LECTURE  XXXVI. 
Rachitis. — Anatomy.— Symptoms. — Etiology. — Treatment.— Osteomalacia.— Hypertro- 
phy and  Atrophy  of  Bone, p.  545 


CHAPTER  XVII. 

CHRONIC  INFLAMMATION  OF  THE  JOINTS. 

LECTURE  XXXVII. 
general  Remarks  on  the  Distinguishing  Characteristics  of  the  Chief  Forms. A.  fun- 
gous and  Suppurative  Articular  Inflammations  (Tumor  Albus),  Symptoms  Anato- 
my, Caries    Sicca,  Suppuration,   Atonic   Forms. — Etiology. — Com-se  and   Pro£{- 
'losis p.  554 


CONTENTS.  Xi 

LECTURE  XXXVIII. 

Treatment  of  Tumor  Albus. — Operations.— Eesectiou  of  the  Joints. — Criticisms  on  the 
Operations  on  the  Ditferent  Joints, page  567 

LECTURE  XXXIX. 
^.—Chronic  Serous  Synovitis. — Hydrops  Articulorum  Chronicus;  Anatomy,  Symp- 
toms, Treatment. — Typical  recurring  Dropsies  of  the  Knee.— Appendix:  Chronic 
Dropsies  of  the  Sheaths  of  the  Tendons,  Synovial  Hernias  of  the  Joints  and  Sub- 
cfttaneous  Mucous  Bursas, p.  573 

LECTURE  XL. 

C. — Chronic  Rheumatic  Inflammation  of  the  Joints. —  Arthritis  Defonnans. — Malum 
Coxse  Senile. — Anatomy,  Different  Forms,  Symptoms,  Diagnosis,  Prognosis, 
Treatment. — Appendix  I. :  Foreign  Bodies  in  the  Joints :  1.  Fibrinous  Bodies ; 
2.  Cartilaginous  and  Bony  Bodies ;  Symptomatology,  Operations. — Appendix  II. : 
Neuroses  of  the  Joints, p.  589 

LECTURE  XLI. 

Anchyloses:  Varieties,  Anatomy,  Diagnosis,  Treatment;  Gradual  Forced  Extension; 
Operations  with  the  Knife, p.  602 

CHAPTER   XVIII. 

CONGENITAL  DEFORMITIES  OF  THE  JOINTS  DUE  TO  MUSCULAR  AND  NER- 
VOUS AFFECTIONS  AND  CICATRICIAL  CONTRACTIONS —LONARTHROSES. 

LECTURE  XLII. 
I.  Deformities  of  Intra-uterine  Origin  due  to  Disturbances  of  Development  of  the 
Joint. — II.  Deformities  occurring  only  in  Children  and  Young  Persons,  caused  by 
Impaired  Growth  of  the  Joint. — III.  Deformities  from  Contractions,  or  Paralysis 
of  Single  Muscles  or  Groups  of  Muscles. — IV.  Limitation  of  Movements  in  the 
Joints  from  Contraction  of  Fasciae  and  Ligaments. — V.  Cicati-icial  Contractions. — • 
Treatment. — Extension  by  Apparatus,  Straightening  under  Ansesthesia. — Com- 
pression.—Tenotomy  and  Myotomy. — Division  of  the  Fascias  and  Articular  Liga- 
ments.— Gymnastics  and  Electricity. — Artificial  Muscles. — Supporting  Appara- 
tus,    p.  614 

CHAPTER   XIX. 

VARICES  AND  ANEURISMS. 
LECTURE  XLIII. 
Varices:  Various  Forms,  Causes,  Various  Localities  where  they  occur, — Diagnosis. — 
Vein-stones. — Varix  Fistulas. — Treatment. — Varicose  Lympliatics,  Lymphorrhoea. 
— Aneurisms  :  Inflammation  of  Arteries. — Aneurysma  Cirsoideum. — Atheroma. — 
Various  Forms  of  Aneurism. — Their  Subsequent  Changes. — Symptoms,  Results, 
Etiology,  Diagnosis. — Treatment :  Compression,  Ligation,  Injection  of  Liquor 
Ferri,  Extirpation, p.  634 

CHAPTER   XX. 

TUMORS. 

LECTURE  XLIV. 

Definition  of  the  Term  Tumor. — General  Anatomical  Remarks ;   Polymorphism  of 

Tissues. — Points  of  Origin  of  Tumors. — Limitation  of  the  Development  of  Cells  to 

Certain  Types  of  Tissue. — Eolation  to  the  Generative  Layers. — Mode  of  Growth. — 

Anatomical  Metamorphosis  of  Tumors ;  their  External  Appearances,    .     .    p.  655 


xii  CONTENTS. 

LECTUEE  XLV. 

Etiology  of  Tumors  ;  Miasmatic  Influence. — Specific  Infection.— Specific  Reaction  ot 
the  Irritated  Tissues ;  its  Cause  is  always  constitutional.— Internal  Irritations ; 
Hypotheses  as  to  the  Character  and  Mode  of  the  Irritant  Action.— Course  and 
Prognosis:  Solitary,  Multiple,  Infectious  Tumors.— Dyscrasia.— Treatment.— Prin- 
ciples of  the  Classification  of  Tumors, page  669 

LECTUEE  XLVI.  * 

*.  Fibromata  :  o,  Soft ;  6,  Hard  Fibroma.— Mode  of  Occurrence  ;  Operations ;  Ligature ; 
Ecrasement ;  Galvano-caustic. — 2.  Lipomata  :  Anatomy ;  Occurrence  ;  Course.  3. 
Chondromata :  Occurrence;  Operation. — 4.  Osteomata:  Forms;  Operation,  p.  684 

LECTUEE  XLVII. 
5.  Myoma. — 6.  Neuroma.— 7.  Angioma:  a,  Plexiform;  5,  Cavernous.— Operations,  p.  704 

LECTURE  XLVIII. 

B.  Sarcomata. — Anatomy :  a.  Granulation  Sarcoma ;  5,  Spindle-celled  Sarcoma ;  c,  Giant- 
celled  Sarcoma ;  d,  Stellate  Sarcoma ;  e,  Alveolar  Sarcoma ;  /,  Pigmented  Sarcoma. 
— Clinical  Appearance. — ^Diagnosis. — Course. — Prognosis. — Mode  of  Infection. — 
Topography. — Central  Osteosarcoma. — Periosteal  Sarcoma. — Sarcoma  of  the  Mam- 
ma, of  the  Salivary  Glands. — 9.  LyTnphomata. — Anatomy. — Relations  to  Leucaemia. 
— Treatment,  .  p.  714 

LECTUEE  XLIX. 

10.  PapUlomata. — 11.  Adenomata, — 12.  Cysts  and  Gystomata. — Follicular  Cysts  of  the 
Skin  and  Mucous  Membranes. — Neoplastic  Cysts. — Cysts  of  the  Thyroid  Gland. — 
Ovarian  Cysts. — Blood-Cysts, p.  743 

LECTUEE  L. 

13  Carcinomata. — Historical  Remarks. — General  Description  of  the  Anatomical  Struct- 
ure.— Metamorphoses. — Forms. — Topography. —  1.  Skin  and  Mucous  Membranes 
with  Pavement  Epithelium. — 2.  Milk  Glands. — 3.  Mucous  Glands  with  Cylindrical 
Epithelium. — 4.  Lachrymal  Glands,  Salivary  Glands,  and  Prostate  Glands. — 5. 
Thyroid  Glands  and  Ovaries. — Treatment.  —  Brief  Remarks  about  the  Diag- 
nosis,      .......  p.  758 


CHAPTER   XXI. 

AMPUTATIONS,  EXABTICULATI0N8,   AND  RESECTIONS. 
LECTURE  LL 

Importance  of  these  Operations. — Amputations  and  Exarticulations. — Indications. — 
Methods. — After-Treatment. — Prognosis. — Conical  Stumps. — Artificial  Limbs. — 
History. — Resection  of  the  Joints.  —  History. — Indications. — Methods. — After- 
Treatment,        p.  802 


LIST    OF    WOODCUTS. 


1  Diagram  of  connective  tissue,  with  capillaries,     .  .  .  •  • 

2  Diagram  of  incision,  capillaries  closed  by  blood-clots,  collateral  distention, 

3.  Diagram  representing  the  surface  of  the  wound  united  by  inflammatory  new 

formation,  .  •  •  •  • 

3  A.  Vessels  from  mesentery  of  frog,  . 
3  B.  Development  of  vessels, 
3  c.  Vessels  in  vitreous  body,  .  .  .  • 

4.  Diagram  of  a  wound  with  loss  of  substance,    . 

5.  Pus-cells  from  fresh  pus,      .... 

6.  Diagram  of  granulation  of  a  wound, 
Y.  Fatty  degeneration  of  cells  from  granulations,     . 
Y  A.  Epithelium  of  the  cornea  of  a  frog, 

8.  Corneal  incision  three  days  old, 

9.  Incised  wound  twenty-four  hours  old,  . 

10.  Cicatrix  nine  days  after  an  incision, 

11.  Granulation-tissue,  .... 

12.  Young  cicatricial  tissue,        .... 

13.  Horizontal  section  through  the  tongue  of  a  dog, 

14.  Same,  ten  days  old,    .  .  .  .  • 

15.  Same,  sixteen  days  old,  .... 

16.  Granulation-vessels,  .... 

17.  Seven-days-old  wound  in  tlie  lip  of  a  dog, 
17  A.  Micrococcus,  .  .  •  •  • 

18.  Cicatrix  from  the  upper  lip  of  a  dog,    . 

19.  Ends  of  divided  muscular  fibres,     . 

20.  Eegenerative  processes  in  transversely-i*triated  muscle, 

21.  Kegeneration  of  nerves,        .  .  .  • 

22.  "  "         .  .  .  . 
22  A.  Nerves  after  division,         .... 

23.  Nodular  nerve-terminations  in  an  old  stump, 

24.  Artery  ligated  in  the  continuity,     . 

25.  Transverse  section  of  a  fresh  thrombus, 

26.  Transverse  section  of  thrombus  six  days  old, 

27.  Ten-days-old  thrombus,  .        «   . 

28.  Completely-organized  thrombus,     .  .  .  .  • 

29.  Longitudinal  section  of  the  ligated  end  of  an  artery, 

30.  Portion  of  a  transverse  section  of  a  vein,  with  organized  thrombus, 

31.  Artery,  injected  six  weeks  after  ligation, 

32.  Artery,  injected  thirty-five  months  after  ligation, 

33.  Artery,  injected  three  months  after  ligation, 

34.  Artery  wounded  on  the  side,  with  clot,     . 


PAGB 

54 
55 

62 
63 
70 
71 
78 
80 
82 
83 
83 
87 


90 
91 
91 
92 
92 
111 
121 
122 
123 
124 
124 
125 
127 
128 
129 
130 
130 
131 
132 
133 
135 
135 
136 
143 


XIV 


LIST   OF  WOODCUTS. 


weeks 


old 


35.  Aneurisma  traumaticum,  .... 

36.  Varix  aneurismaticus,  ..... 

37.  Aneurisma  varicosum,     ..... 

38.  Granular  and  crystalline  haematoidin, 

39.  Detachment  of  dead  connective  tissue  in  contused  wounds, 

40.  Central  end  of  a  torn  brachial  artery, 

41.  Evulsed  middle  finger,    ..... 

42.  Arm  torn  out,  with  scapula  and  clavicle,    . 

43.  Longitudinal  section  of  a  fracture  four  days  old, 

44.  Diagram  of  a  longitudinal  section  of  a  fracture  fifteen  days  old, 

45.  Diagram  of  a  longitudinal  section  of  a  fracture  twenty -four 
4(5.  Fracture,  with  dislocation,  after  twenty-seven  days, 

47.  Old  united  oblique  fracture,       .... 

48.  Longitudinal  section  through  the  cortical  substance, 

49.  Inflammatory  new  formation  in  Haversian  canals, 

50.  Ossification  of  inflammatory  neoplasia  on  the  surface  of  the  bone  and  in  the 

Haversian  canals,  ..... 

51.  Artificially -injected  external  callus,  five  days  old, 

52.  Artificially-injected  transverse  section,  eight  days  old, 

53.  Ossifying  callus  on  the  surface  of  a  hollow  bone, 

54.  Detachment  of  a  superficial  piece  of  a  flat  bone, 

55.  Detachment  of  a  necrosed  portion  of  bone, 
5f'.  Fracture  of  a  long  bone  with  external  wound, 

57.  Necrosis  of  sawed  surface  of  femur, 

58.  Bullets  of  various  styles,       .... 

59.  Tiemann's  bullet-forceps,  .... 

60.  Gunshot-fractures  of  femur  and  tibia, 

61.  Traces  of  lightning,  ..... 

62.  Conjunctiva  affected  with  catarrh,  . 

63.  Tissue  from  a  prepuce  infiltrated  from  inflammation, 

64.  Purulent  infiltration  of  the  cutis  connective  tissue, 

65.  Purulent  infiltration  of  the  cellular  membrane, 

66.  Vessels  of  the  walls  of  an  abscess, 
66  a.  Growth  of  fungus  from  the  cornea  of  a  rabbit, 

67.  Venous  thrombus,     ..... 

68.  Fever  curve  after  amputation  of  the  arm, 

69.  Fever  curve  after  resection  of  carious  wrist, 

70.  Fever  curve  in  erysipelas,  .... 

71.  Fever  curve  in  septicaemia,  .... 
71  A.  Giant  cells  from  tubercles  in  various  stages, 
71  B.  Minute  tubercles  in  the  peritoneum  and  on  a  cerebral  artery, 
71  0.  Minute  tubercles  on  a  cerebral  artery, 

72.  Cutaneous  ulcer  of  the  leg,  .... 

73.  Granulations  of  a  common  ulcer, 

74.  Caries  superficialis  of  the  tibia, 

75.  Section  of  a  piece  of  carious  bone, 
75  A.  Ostitis  malacissans,  .  .  ... 

76.  Disappearance  of  chalky  salts  from  periphery  of  bone, 

77.  Sclerosed  tibia  and  femur,    .... 

78.  Point  of  caseous  degeneration  in  the  spinal  column,  . 

79.  Destruction  of  the  vertebral  column, 

80.  Total  necrosis  of  the  diaphysis  of  a  hollow  bone, 

81.  Total  necrosis  of  the  diaphysis  of  a  hollow  bone  with  detached  sequestrum, 

82.  Total  necrosis  of  the  diaphysis  of  a  hollow  bone  after  removal  of  sequestrum, 


PAGE 

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145 
146 
155 
169 
192 
192 
192 
201 
201 
203 
204 
204 
205 
206 

208 

209 

209 

210 

229 

230 

231 

231 

275 

281 

283 

294 

311 

314 

315 

316 

317 

373 

392 

398 

399 

401 

40Gi 

460 

461 

462 

481 

486 

498 

500 

506 

507 

508 

511 

514 

632 

534 

534 


LIST  OF  WOODCUTS. 


XV 


not. 

83.  Total  necrosis  of  the  diaphysis  of  the  femur,    . 

84.  Total  necrosis  of  the  diaphysis  of  the  tibia, 

85.  Necrosis  of  the  lower  half  of  diaphysis  of  femur, 

86.  The  body  extracted  from  Fig,  85, 

87.  Diagram  of  partial  necrosis  of  a  hollow  bone,    . 

88.  Diagram  of  Fig.  87  in  the  later  stages, 

89.  Fig.  88,  after  removal  of  the  sequestrum, 

90.  Scapula  of  a  dog,  resected  with  and  without  periosteum, 

91.  Kachitic  malformations  of  the  leg, 

92.  Woman  with  extensive  osteomalacia, 

93.  Section  of  knee-joint  with  fungous  inflammation, 

94.  Degeneration  of  cartilage  in  fungous  inflammation, 

95.  Subchondral  caries  of  the  astragalus, 

96.  Atonic  ulceration  of  cartilage  from  the  knee-joint, 

97.  Diagram  of  the  ordinary  ganglion, 

98.  Hernial  protrusions  of  synovial  membrane, 

99.  Degeneration  of  the  cartilage  in  arthritis  deformans, 

100.  Osteophytes  in  arthritis  deformans, 

101.  Fungous  inflammation  of  the  elbow-joint, 

102.  Osteophytes  in  arthritis  deformans, 

103.  Multiple  articular  bodies, 

104.  Band-like  adhesions  in  a  resected  elbow-joint, 

105.  Adhesion  of  articular  surfaces  of  the  elbow-joint, 

106.  Elbow-joint  anchylosed  by  bony  bridges,     . 

107.  Section  of  the  shoulder-joint, 

108.  Section  of  tlie  shoulder-joint, 

109.  Contraction  of  the  fascia  lata, 

110.  Cicatricial  contractions  after  burns,   . 

111.  Cicatricial  contractions  after  burns, 

112.  Subcutaneously-divided  tendon, 

113.  Varices,       .... 

114.  Cirsoid  aneurism  of  the  scalp, 

115.  Small  fibroma, 

116.  From  a  myo-fibroma,  . 

117.  Vessels  from  a  cutis  fibroma, 

118.  Neuroma,  .... 

119.  Fibro-sarcomatous  neuromata, 

120.  Cartilage  tissue  from  chondromata,    . 

121.  Chondroma  of  the  fingers, 

122.  Odontoma  of  a  back  tooth, 

123.  Section  of  an  odontoma,     . 

124.  Pedunculated  spongy  exostosis, 

125.  Ivory  exostosis  of  the  skull, 

126.  Section  from  an  ivory  osteoma, 

127.  Osteoma  of  the  muscular  attachments, 

128.  Vessels  from  a  plexiform  angioma,    . 

129.  Jlesh-work  from  a  cavernous  angioma, 

130.  Tissue  of  granulation-sarcoma, 

131.  Tissue  of  glio-sarcoma, 

132.  Tissue  of  a  spindle-celled  sarcoma,    . 

133.  Giant-cells  from  a  sarcoma, 

134.  Giant-celled  sarcoma  with  cysts, 

135.  Cell-globules  from  a  sarcoma, 

136.  Mucous  tissue  from  a  myxosarcoma, 


XVI 


LIST  OF  WOODCUTS. 


FIO. 

137.  Mucous  tissue  from  an  adenomyxoma,  .  , 

138.  Alveolar  sarcoma  from  the  deltoid  muscle, 

139.  Alveolar  sarcoma  from  the  tibia, 
139  A.  Villous  sarcoma,  ..... 

139  B.  Psammona,      ...... 

139  c.  From  a  cerebral  tumor,    ..... 

139  D.  Plexiform  sarcoma,     ..... 

139  E.  From  a  cylindroma  of  the  orbit, 

140.  Central  osteosarcoma  of  the  ulna, 

141.  Section  of  Fig.  140,  ..... 

142.  Central  osteosarcoma  of  the  lower  jaw,  . 

143.  Section  of  Fig.  142,  ..... 

144.  Compound  cystoma  of  the  thigh,  ... 

145.  Periosteal  sarcoma  of  the  tibia,    .... 

146.  Section  of  Fig.  145,       ..... 

147.  From  an  adeno-sarcoma  of  the  female  breast,    . 

148.  From  the  cortical  layer  of  a  hyperplastic  lymphatic  gland 

149.  Sections  of  a  wart,  ..... 

150.  From  a  mucous  polypus,  .... 

151.  Adenoma  of  the  thyroid,  ..... 

152.  Commencing  epithelial  cancer  of  the  lip, 

153.  Flat  epithelial  cancer  of  the  cheeks, 

154.  Elements  of  an  epithelial  carcinoma  of  the  lip, 

155.  From  an  epithelial  cancer  of  the  hand,    , 

156.  Vessels  from  a  carcinoma  of  the  penis, 

157.  Papillary  formation  of  a  villous  cancer,  . 

158.  Mammary  cancer,  acinous  form, 

159.  Soft  mammary  cancer,       ..... 

160.  From  a  mammary  cancer,        .... 

161.  Connective-tissue  frame-work  of  a  cancer  of  breast, 

162.  Cancer  of  breast,  tubular  form, 

163.  Cancer  of  the  mamma  from  an  atrophied  part,  . 

164.  Vascular  net-work  from  a  very  young  nodule, 

165.  Vascular  net-work  around  points  of  softening,  . 

166.  Connective-tissue  infiltration,  etc.,    . 

167.  Cellular  infiltration  of  fatty  tissue,  etc., 

168.  Cancer  of  the  mucous  glands  from  nose, 

169.  Adenoid  cancer  of  the  rectum,     .... 


PAGE 

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720 
720 
722 
723 
724 
725 
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729 
729 
730 
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731 
732 
732 
734 
737 
744 
747 
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766 
766 
767 
768 
769 
773 
776 
776 
777 
778 
778 
779 
780 
781 
785 
786 
788 
789 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS. 


LECTURE  I. 


INTRODUCTION. 


Eolation  of  Surgery  to  Internal  Medicine. — Necessity  of  the  Practising  Physician 
being  acquainted  with  both. — Historical  Eemarks. — Nature  of  the  Study  of  Sur 
gery  in  the  German  High-schools. 

Gentlemen  :  The  study  of  surgery,  which  you  begin  with  this 
lecture,  is  now,  in  most  countries,  justly  regarded  as  a  necessity  for 
the  practising  physician.  We  consider  it  a  happy  advance  that  the 
division  of  surgery  from  medicine  no  longer  exists,  as  it  did  formerly. 
The  difference  between  internal  medicine  and  surgery  is  in  fact  only 
apparent ;  the  distinction  is  artificial,  founded  though  it  be  on  history, 
and  on  the  large  and  increasing  literature  of  general  medicine.  In 
the  course  of  this  work  your  attention  will  often  be  called  to  the 
frequency  with  which  surgery  must  consider  the  general  state  of  the 
body,  to  the  analogy  between  the  diseases  of  the  external  and  inter- 
nal parts,  and  to  the  fact  that  the  whole  difference  depends  on  our 
seeing  before  us  the  changes  of  tissue  that  occur  in  surgical  diseases, 
while  we  have  to  determine  the  affections  of  internal  organs  from  the 
symptoms.  The  action  of  the  local  disturbances  on  the  body  at  large 
must  be  understood  by  the  surgeon,  as  well  as  by  any  one  who  pays 
especial  attention  to  diseases  of  the  internal  organs.  In  shorty  the 
surgeon  can  only  judge  safely  and  correctly  of  the  state  of  Jus  patient 
when  he  is  at  the  same  time  a  physician.  Moreover,  the  physician  who 
proposes  refusing  to  treat  surgical  patients,  and  to  attend  solely  to  the 
treatment  of  internal  diseases,  must  have  some  surgical  knowledge,  or 
he  will  make  the  grossest  blunders.  Apart  from  the  fact  that  the 
country  physician  does  not  always  have  a  colleague  at  hand  to  whom 
he  can  turn  over  his  surgical  patients,  the  life  of  the  patient  often  de- 
pends on  the  correct  and  inst;mtaneous  recognition  of  a  sui-gical  disease. 


J,  INTRODUCTION 

\^^hen  blood  spouts  forcibly  from  a  wound,  or  a  foreign  body  has 
entered  the  windpipe,  and  the  patient  is  threatened  with  suffocation, 
then  surgical  aid  is  required,  and  quickly  too,  or  the  patient  dies.  In 
other  cases,  also,  the  physician  ignorant  of  surgery  may  do  much  harm 
by  not  recognizing  the  importance  of  a  case  ;  he  may  allow  a  disease 
to  become  incurable,  and  by  his  deficient  knowledge  cause  unspeakable 
injury,  in  a  case  which  might  have  been  relieved  by  early  surgical 
treatment.  Hence  it  is  inexcusable  for  a  physician  obstinately  to 
stick  to  the  idea  of  only  practising  internal  medicine ;  still  more  inex- 
cusable is  it,  in  this  idea,  to  neglect  the  study  of  surgery  :  "  I  will  not 
operate,  because  in  ordinary  practice  there  is  so  little  operating  to  be 
done,  and  I  am  not  at  all  suited  for  an  operator  !  "  As  if  surgery  con- 
sisted only  in  operations.  I  hope  to  give  you  a  better  idea  of  this 
branch  of  medicine  than  is  conveyed  by  the  above  remark,  which  un- 
fortunately is  too  popular. 

From  the  fact  that  surgery  has  to  deal  chiefly  with  patent  dis- 
eases, it  certainly  has  an  easier  position  in  regard  to  anatomical  diag- 
nosis ;  but  do  not  regard  this  advantage  too  highly.  Besides  the  fact 
that  surgical  diseases  also  often  lie  deeply  hidden,  more  is  demanded 
from  a  surgical  diagnosis  and  prognosis,  and  even  in  the  treatment,  tlian 
from  the  therapeutic  action  of  internal  medicine.  I  do  not  deny  that 
in  many  respects  internal  medicine  may  hold  a  higher  rank,  just  on 
account  of  the  difficulties  it  has  (and  often  so  brilliantly  overcomes) 
in  localizing  and  recognizing  disease.  Very  fine  operation  of  the  mind 
is  often  necessary  to  come  to  a  proper  conclusion,  from  the  combination 
of  symptoms,  and  the  results  of  the  examination.  Ph3^sicians  may 
point  with  pride  to  the  anatomical  diagnosis  of  diseases  of  the  heart  and 
lungs,  where  the  careful  student  succeeds  in  giving  as  accurate  a  de- 
scription of  the  changes  in  the  diseased  organ  as  if  he  had  it  right 
under  his  eyes.  How  wonderful  it  is  to  gain  an  accurate  knowledge 
of  the  morbid  state  of  hidden  organs,  such  as  the  kidneys,  liver, 
spleen,  intestines,  brain,  and  spinal  marrow,  by  the  examination  of  a 
patient  and  the  combination  of  symptoms  !  What  a  triumph  to  diag- 
nose diseases  of  organs  of  which  we  do  not  know  even  the  physiolo- 
gical function,  as  of  the  supra-renal  capsules  !  This  is  some  compensa- 
tion for  the  fact  that,  in  internal  medicine,  we  must  more  frequently 
acknowledge  the  impotence  of  our  treatment  than  is  the  case  in 
surgery,  although,  from  the  advances  in  anatomical  diagnosis,  we  have 
become  more  certain  of  what  we  can  do,  and  of  what  we  cannot. 

The  irritation  of  the  finer,  cultivated  portions  of  the  mind  in  inter- 
nal medicine  is,  however,  richly  balanced  by  the  greater  certainty  and 
clearness  of  diagnosis  and  treatment  in  surgery,  so  that  the  two 
branches  of  medical  science  are  exactlv  on  a  par.      And  it  must  not 


INTllODUCTION.  3 

be  forgotten  that  the  anatomical  diagnosis — I  mean  the  recognition  of 
the  pathological  changes  in  the  diseased  organ — is  only  one  means  to 
the  end,  which  is  the  cure  of  the  disease.  TJie  true  problems  for  the 
physician  are  to  find  out  the  causes  of  the  morbid  process^  to  prog' 
nosticate  the  course,  conduct  it  to  a  favorable  terminatioti,  or  control 
it,  and  these  are  equally  difjicxdt  in  internal  and  external  medicine. 
Only  one  thing  more  is  required  of  the  practical  surgeon  :  this  is,  the 
art  of  operating.  This,  like  every  art,  has  its  knack ;  the  facility  of 
operating  secondarily  depends  on  accurate  knowledge  of  anatomy,  on 
practice,  and  on  personal  aptitude.  This  aptitude  may  also  be  culti- 
vated by  persevering  practice.  Just  remember  how  Demosthenes  suc- 
ceeded in  acquiring  fluency  in  speaking. 

This  knack,  which  is  certainly  necessary,  has  long  separated  sur- 
gery from  medicine  in  tlie  strict  sense ;  w^e  may  historically  follow 
this  separation  as  it  constantly  became  more  practically  felt,  till  in 
this  century  it  was  finally  recognized  as  impractical  and  was  abol- 
ished. The  word  "  chirurgery  "  at  once  expresses  that  originally  it 
%vas  regarded  as  entirely  manual,  for  it  comes  from  x^'^-P  f^^icl  tpyov, 
vhich  literally  mean  "  hand-work,"  or,  in  the  pleonasm  of  the  middle 
ages,  "  hand-work  of  chirurgery," 

Little  as  it  comes  within  the  scope  of  this  work  to  give  a  complete 
sketch  of  the  history  of  surgery,  it  still  seems  to  me  important  and  in- 
teresting to  give  you  a  short  sketch  of  the  external  and  internal  de- 
velopment of  our  science,  which  will  explain  to  you  some  of  the  va- 
rious regulations  affecting  the  so-called  "  medical  staff"  still  existing  in 
different  states.  A  fuller  history  of  surgery  can  only  be  of  use  to  you 
hereafter,  when  you  shall  have  acquired  some  knowledge  of  the  value 
or  worthlessness  of  certain  systems,  methods,  and  operations.  Then, 
in  the  historical  development  of  the  science,  especially  as  regards  op- 
erative surgery,  you  will  find  the  key  for  some  surprising  and  for 
some  isolated  experience,  also  for  much  that  is  incomplete.  Many 
things  that  may  be  necessary  for  the  comprehension  of  the  subjects,  I 
shall  relate  to  you  when  speaking  of  the  different  diseases ;  now,  I 
shall  only  present  a  few  prominent  points  in  the  develoioment  of  sur- 
gery and  of  its  present  position. 

Among  the  people  in  former  times,  the  art  of  healing  was  inti- 
mately associated  with  religious  education.  The  Hindoos,  Arabs,  and 
Egyptians,  as  well  as  the  Greeks,  considered  the  art  of  healing  as  a 
manifestation  made  by  the  gods  to  the  priests,  and  then  spread  by  tradi- 
tion. Philologists  were  not  agreed  as  to  the  age  of  the  Sanscrit  writ- 
ings discovered  not  long  since ;  formerly  their  origin  Avas  placed  at 
1000-1400  B.  c,  now  it  is  considered  certain  that  they  were  Avritten 
in  the  first  century  of  the  Christian  era.    The  Agur-Veda  ("  Book  of 


i  INTRODUCTION. 

the  Art  of  Life  ")  is  the  most  important  Sanscrit  work  for  medicine  ;  it 
is  the  production  of  Susrutas.  It  very  probably  originated  in  the  time 
of  the  Roman  Emperor  Augustus.  The  art  of  healing  was  regarded 
as  a  whole,  as  is  indicated  by  tlie  following:  "  It  is  only  the  combina- 
tion of  medicine  and  surgery  that  makes  the  complete  physician.  The 
physician  lacking  knowledge  of  one  of  these  branches  is  like  a  bird 
with  only  one  wing."  At  that  time  surgery  was  without  doubt  b}' 
far  the  more  advanced  part  of  the  medical  art.  A  large  number  of  op- 
erations and  instruments  are  spoken  of;  still,  it  is  truly  said  "  the  best 
of  all  instruments  is  the  hand ; "  the  treatment  of  wounds  given  is 
simple  and  proper.     Most  surgical  injuries  were  already  known. 

Among  the  Greeks  all  medical  knowledge  at  first  centred  \nJEs- 
culajnys,  a  son  of  Apollo,  and  a  scholar  of  the  Centaur  Chiron. 
Many  temples  were  built  to  ^sculapius,  and  the  art  of  healing  was 
handed  down  by  tradition  tlu-ough  the  priests  of  these  temples  ;  the 
number  of  these  temples  induced  various  schools  of  JEsculapides,  and, 
although  every  one  entering  the  temple  as  a  priest  had  to  take  an 
oath,  which  has  been  handed  down  to  our  own  times  (although  of  late 
its  genuineness  appears  rather  doubtful),  that  he  would  only  teach 
the  art  of  healing  to  his  successors,  still,  as  appears  from  various  cir- 
cumstances, even  at  that  time  there  were  other  physicians  besides  the 
priests.  From  one  part  of  the  oath,  even,  it  is  evident  that  then  as  now 
there  were  phj'sicians  who,  as  specialists,  confined  themselves  to  cer- 
tain operations  ;  for  it  says  :  "  Furthermore,  I  will  never  cut  for  stone, 
but  will  leave  this  operation  to  men  of  that  occupation."  Of  the 
different  varieties  of  ph3'sicians  we  know  nothing  more  accurate  till 
the  time  of  JTij^j^ocrates  ;  he  was  one  of  the  last  of  the  Asklepiades. 
He  was  born  4G0  b.  c,  on  the  island  of  Cos ;  lived  partly  in  Athens, 
partly  in  Thessalian  towns,  and  died  377  b.  c.  at  Larissa.  We  might 
expect  that  medicine  would  be  considered  scientifically  at  this  time, 
when  the  names  of  Pythagoras,  Plato,  and  Aristotle,  Avere  shining  in 
Grecian  science  ;  and  in  fact  the  works  of  Hippocrates,  many  of  which 
are  still  preserved,  arouse  our  astonishment.  The  clear  classical  de- 
scription, the  arrangement  of  the  whole  material,  the  high  regard  for 
the  healing  art,  the  sharp  critical  observations,  that  appear  in  the 
works  of  Hippocrates,  and  compel  our  admiration  and  respect  for  an- 
cient Greece  on  this  branch  also,  clearly  show  that  it  is  not  a  case  of 
])lind  belief  in  traditional  medical  dogmas,  but  that  there  was  already 
a  scientific  and  elaborately  perfected  medicine.  In  the  Hippocratic 
schools  the  art  of  healing  formed  one  whole ;  medicine  and  surgery 
were  united,  bvit  there  were  various  classes  of  medical  practitioners  ; 
besides  the  Asklepiades  there  were  other  educated  physicians,  as  well 
as  more  mechanically  instructed  medical  assistants,  gymnasts,  quacks, 


INTRODUCTION.  5 

and  workers  of  miracles.  The  physicians  took  scholars  to  train  in  the 
art  of  healing ;  and,  according  to  some  remarks  of  Xenophon,  there 
were  also  special  army  physicians;  especially  in  the  Persian  wars, 
the}',  together  with  the  soothsayers  and  flute-players,  had  their  places 
near  the  royal  tent.  It  may  'he  readily  understood  that,  at  a  time 
when  so  much  was  thought  of  corporeal  beauty,  as  was  the  case 
among  the  Greeks,  external  injuries  would  claim  special  attention. 
Hence,  among  physicians  of  the  Hippocratic  era,  fractures  and  sprains 
were  particularly  studied ;  still,  some  severe  operations  are  treated  of, 
as  also  numbers  of  instruments  and  other  apparatuses.  They  seem  to 
have  been  very  backward  regarding  amputations ;  probably  the 
Greeks  preferred  dying  to  prolonging  life  after  they  were  mutilated 
The  limb  was  only  removed  when  it  was  actually  dead,  gangrenous. 

The  teachings  of  Hippocrates  could  not  at  first  be  carried  any  fur- 
ther, for  lack  of  knowledge  of  anatomy  and  physiology.  It  is  true 
there  was  a  faint  efibrt  made  in  this  direction  in  the  scientific  schools 
of  Alexandria,  which  flourished  for  some  centuries  under  the  Ptole- 
mies, and  by  means  of  which,  after  the  wars  of  Alexander  the  Great, 
the  Grecian  spirit  was  spread,  at  least  temporarily,  over  part  of  the 
Orient ;  but  the  Alexandrian  physicians  soon  lost  themselves  in  phil- 
osophical systems,  and  only  advanced  the  science  of  healing  a  little 
by  a  few  anatomical  discoveries.  In  this  school  the  art  of  healing 
was  at  first  divided  into  three  separate  parts — dietetics,  internal  medi- 
cine, and  surgery.  Along  with  Grecian  culture,  their  knowledge  of 
medicine  was  also  brought  to  Rome.  The  first  Roman  physicians  were 
Grecian  slaves ;  the  freedmen  among  them  were  allowed  to  erect 
baths ;  here,  first,  barbers  and  bathers  became  our  rivals  and  col- 
leagues, and  for  a  long  time  they  injured  the  respectability  of  the  pro- 
fession in  Rome.  Gradually  the  philosophically-minded  took  posses- 
sion of  the  writings  of  Hippocrates  and  the  Alexandrians,  and  them- 
selves practised  medicine,  without,  however,  adding  to  it  much  that  was 
new.  The  great  lack  of  original  scientific  production  is  shown  in  the 
encyclopedial  re\'ision  of  the  most  varied  scientific  works.  The  most 
celebrated  work  of  this  nature  is  the  "  De  Artibus  "  of  Aulus  Corne- 
lius Celsus  (from  25-30  b,  c.  to  45-50  a.  d.,  in  the  time  of  the  Em- 
perors Tiberius  and  Claudius).  Eight  books  of  this,  "Z^e  3Iedicina^'* 
have  come  down  to  our  time ;  from  these  we  knoAV  the  state  of  medi- 
cine and  surgery  at  that  time.  Valuable  as  are  these  relics  from  the 
Roman  ages,  they  are  only,  as  we  have  said,  a  compendium,  such  as 
is  often  published  at  the  present  day.  It  has  even  been  denied  that 
Cels^is  was  a  practising  physician,  but  this  is  improbable ;  from  his 
v-ritings  we  must,  at  all  events,  credit  Celsus^Yii\\  using  his  own  judg- 
ment.  The  seventh  and  eighth  books,  which  treat  on  surgery,  could  not 


g  INTRODUCTION. 

have  been  Amtten  so  clearly  by  any  one  who  had  no  practical  knowl- 
edge of  his  subject.  Hence  we  see  tliat,  since  the  time  of  Hippo- 
crates and  the  Alexandria  school,  surgery,  especially  the  operative 
part,  had  made  no  great  progress.  Celsus  speaks  of  plastic  opera- 
tions, of  hernia,  and  gives  a  method  of  amputation  which  is  still  occa- 
sionally employed.  One  part,  from  the  seventh  book,  where  he  speaks 
of  the  qualifications  of  the  perfect  surgeon,  is  quite  celebrated,  as  it 
is  characteristic  of  the  spirit  which  reigns  in  the  book ;  I  give  it  to 
you :  "  The  surgeon  should  be  3'oung,  or  at  least  little  advanced  in 
age,  with  a  hand  nimble,  firm,  and  never  trembling ;  equally  dexter- 
ous with  both  hands;  vision,  shai-p  and  distinct;  bold,  unmerciful,  so 
that,  as  he  wishes  to  cure  his  jDatient,  he  ma}"  not  be  moved  by  his 
cries  to  hasten  too  much,  or  to  cut  less  than  is  necessarj-.  In  the 
same  way  let  him  do  every  thing  as  if  he  were  not  afiected  by  the 
cries  of  the  patient." 

Claudius  Galenus  (131-201  a.  d.)  must  be  regarded  as  a  phe- 
nomenon among  the  Roman  physicians ;  eighty-three  undoubtedly 
genuine  medical  writings  of  his  have  come  down  to  us.  Galen  re- 
turned again  to  the  Hijipocratic  belief,  that  observation  must  form 
the  foundation  of  the  art  of  healing,  and  he  advanced  anatomy  great- 
1}";  he  made  dissections  chiefly  of  asses,  rarely  of  human  beings. 
Galen''s  anatomy,  as  well  as  the  entire  philosophical  sj'stem  into 
which  he  brought  medicine,  and  wliich  seemed  to  him  even  more  im- 
portant than  observation  itself,  has  stood  firm  over  a  thousand  years. 
He  occupies  a  very  prominent  position  in  the  history  of  medicine.  He 
did  little  for  surgery  in  particular ;  indeed,  he  practised  it  little,  for  in 
his  time  there  were  special  surgeons,  either  gj-mnasts,  bathers,  or 
barbers,  and  so  unfortunately  surgery  was  handed  down  by  tradition 
as  a  mechanical  art,  while  internal  medicine  was,  and  long  remained, 
in  the  hands  of  philosophic  phj^sicians ;  the  latter  knew  and  com- 
mented freely  on  the  surgical  wi'itings  of  Hippocrates^  the  Alexandri- 
ans^ and  Celsus,  still  they  paid  little  attention  to  surgical  practice. 
As  we  are  only  giving  a  faint  sketch,  we  might  here  skip  several  cen- 
turies, or  even  a  thousand  years,  during  which  surgery  made  scarcely 
any  progress,  indeed  retrograded  occasionally.  The  Byzantine  era  of 
the  empire  was  particularly  imfavorable  to  the  advance  of  science, 
there  was  only  a  short  flickering  up  of  the  Alexandria  school.  Even 
the  most  celebrated  physicians  of  the  later  Roman  times,  Antyllus  (in 
the  third  century),  Orihasiiis  (326-403  A.  d.),  Alexander  of  Tralles 
(525-605  A.  D.),  Faidus  of  ^gina  (600),  did  relatively  little  for  sur- 
gery. Some  advance  had  been  made  in  the  position  and  scholarly  at- 
tainments of  physicians ;  under  Nero  there  was  a  gj^mnasium  ;  under 
Hadrian  an  athcna?um,  scientific  institutions  where  medicine  also  was 


INTIIODUCTIOX.  7 

taugnt;  under  Trajan,  there  was  a  special  medical  school.  Militarj' 
medical  service  was  attended  to  among  the  Romans,  and  there  were 
special  court  physicians,  "  archiatri  palatini,"  with  the  title  of  "  per- 
fectissime,"  "  eques,"  or  **  comes  archiatrorum,"  just  as,  among  the 
Germans,  "  Hofrathe,"  "  Geheimrathe,"  "  Leibarzte,"  etc.  That,  as  a 
result  of  the  fall  of  science  in  the  Byzantine  reign,  the  art  of  healing 
did  not  totally  degenerate,  is  due  to  the  Arabians.  The  wonderful 
elevation  that  this  people  attained  under  Mohammed,  after  the  year 
608,  aided  in  preserving  science.  The  Hippocratic  knowledge  of 
medicine,  Avitli  the  later  additions  to  it,  passed  to  the  Arabians 
through  the  Alexandrian  school,  and  its  branches  in  the  Orient,  the 
schools  of  the  Nestorians ;  they  cherished  it  till  their  power  was  de- 
mohshed  by  Charles  Martel,  and  returned  it  to  Europe  by  way  of 
Spain,  though  somewhat  changed  in  form.  Mhazes  (850-932),  Avi- 
ceima  (980-1037),  ^/5ucas(!S  (f  1106),  and  Avenzoar  (f  1162),  are  the 
most  celebrated,  and  for  surgery  the  most  important,  of  the  Arabian 
physicians  whose  writings  have  been  preserved;  the  writings  of  the 
latter  are  the  most  important  for  surgery.  Operative  surgery  suffered 
greatly  from  the  dread  the  Arabians  had  of  blood,  which  was  partly 
due  to  the  laws  of  the  Koran ;  it  caused  the  employment  of  the  ac- 
tual cautery  to  an  extent  that  Ave  can  hardly  comprehend.  The  dis- 
tinction of  surgical  diseases  and  the  certainty  of  diagnosis  had  de- 
■  cidedly  increased.  Scientific  institutions  were  much  cultivated  by  the 
Arabians ;  the  most  celebrated  was  the  school  of  Cordova ;  there  were 
also  hospitals  in  many  places.  The  study  of  medicine  was  no  longer 
chiefly  private,  but  most  of  the  students  had  to  complete  their 
studies  at  some  scientific  institution.  This  also  had  its  effect  on  the 
nations  of  the  West.  Besides  Spain,  Italy  was  the  chief  place  where  the 
sciences  were  cultivated.  In  southern  Italy  there  was  a  very  cele- 
brated medical  school  at  Salerno  ;  it  was  probably  founded  in  802 
by  Charles  the  Great,  and  Avas  at  its  zenith  in  the  twelfth  century ; 
according  to  the  most  recent  ideas,  this  was  not  an  ecclesiastical 
school,  but  all  the  pupils  were  of  the  laity.  There  were  also  female  pu- 
pils, who  were  of  a  literary  turn ;  the  best  known  among  these  was 
Trotula.  Original  observations  were  not  made  there,  or  at  least  to  a 
very  slight  extent,  but  the  Avritings  of  the  ancients  were  adhered  to. 
This  school  is  also  interesting  from  the  fact  that  it  is  the  first  cor- 
poration that  we  find  liaA^ing  the  right  to  bestow  the  titles  "  doctor  " 
and  "  magister." 

Emperoi's  and  kings  gradually  took  more  interest  in  science,  and 
Founded  universities ;  thus  universities  were  founded  in  Naples  in 
1224,  in  Pa  via  and  Padua  in  1250,  in  Paris  in  1205,  in  Salamanca  in 
1243,  in  Prague  in  1348,  and  they  were  invested  with  the  right  of 


3  INTRODUCTION. 

conferring  academical  honors.  Philosophy  was  the  science  to  which 
most  attention  was  paid,  and  for  a  long  time  Medicine  preserved  her 
philosophical  robe  in  the  universities ;  in  some  cases  they  adhered  to 
Galen's  system,  in  others  to  the  Arabian  or  to  new  medico-philo- 
sophical systems,  and  registered  all  their  observations  under  these 
heads.  This  was  the  great  obstacle  to  the  progress  of  the  natural 
sciences,  a  mental  slavery,  from  which  even  men  of  intellect  could  not 
free  themselves.  The  anatomy  of  Mondino  de  Luzzi  (1314)  differs 
very  little  from  that  of  Galen,  in  spite  of  the  fact  that  the  author 
bases  it  on  dissections  he  made  of  some  human  bodies.  In  surgery 
there  were  no  actual  advances  ;  Lanfranchi  (fl300),  Guido  of  Caull- 
aco  (beginning  of  the  fourteenth  centurj-),  Branca  (middle  of  the 
fifteenth  centur}'),  are  a  few  of  the  noteworthy  surgeons  of  those  times. 
Before  passing  to  the  flourisliing  state  of  the  natural  sciences  and  of 
medicine  in  the  sixteenth  century,  we  must  review  briefly  the  composi- 
tion of  the  medical  profession  in  the  times  of  which  we  have  been 
speaking,  as  this  is  important  for  the  history.  First,  there  were  philo- 
sophically educated  physicians  either  lay  or  monk,  who  had  learned 
medicine  in  the  universities  or  other  schools ;  i.  e.,  they  had  studied 
the  old  writings  on  anatomy,  surgery,  and  special  medicine  ;  they  prac- 
tised, but  paid  little  attention  to  svirgery.  Another  seat  of  learning 
was  in  tlie  cloisters  ;  the  Benedictines  especially  paid  a  great  deal  of 
attention  to  medicine  and  also  practised  surgery,  although  the  supe- 
riors disliked  to  see  this,  and  occasionally  special  dispensation  had  to 
be  obtained  for  an  operation.  The  regular  practising  physicians  were 
sometimes  located,  sometimes  travelling.  The  former  were  usually 
educated  at  scientific  schools  and  received  permission  to  practise  on 
certain  conditions.  In  1229,  the  emperor  Frederick  II.  pubhshed  a 
law  that  these  physicians  should  study  logic  (that  is,  philosophy  and 
philology)  three  years,  then  medicine  and  svirgery  five  years,  and  then 
practise  for  some  time  under  an  older  physician;  before  receiving 
permission  to  practise  independently,  or,  as  an  examiner  lately  said, 
of  physicians  who  had  just  received  their  degree,  "  till  they  were  let 
loose  on  the  public."  Besides  these  located  physicians,  of  whom  a 
great  part  were  "  doctor  "  or  "  magister,"  there  were  many  "  travelling 
doctors,"  a  sort  of  "  travelling  student "  who  went  through  the  market- 
towns  in  a  wagon  with  a  merry  Andrew,  and  practised  solely  foi 
money.  This  genus  of  the  so-called  charlatans,  which  played  an  im 
portant  part  in  the  poetry  of  the  middle  ages,  and  is  still  gleefully 
greeted  on  the  stage  by  the  public,  carried  on  a  rascally  trade  in  the 
middle  ages  ;  they  were  as  infamous  as  pipers,  jugglers,  or  hangmen  ; 
even  now  these  travelling  scholars  are  not  all  dead ;  although,  in  the 
nineteenth  century,  they  do  not  ply  their  trade  in  the  market-place,  but 


INTRODUCTION.  g 

ji  the  drawing-rooms  as  workers  of  miracles,  especially  as  cancer-doc- 
tors, herb-doctors,  somnambulists,  etc.  Let  us  now  inquire  the  rela- 
tion, of  those  who  practised  surgery,  to  the  above  company.  This 
branch  of  medicine  was  occasionally  resorted  to  by  almost  all  of  the 
above  ;  still  there  were  special  surgeons,  who  united  into  guilds  and 
formed  honorable  societies ;  they  received  their  practical  knowledge 
first  from  a  master,  under  whom  they  studied,  and  subsequently  from 
books  and  scientific  institutions.  Surgical  practice  was  chiefly  confined 
to  these  persons,  who  were  mostly  located,  but  sometimes  travelled 
about  as  "  hernia  doctors,"  "  operators  for  stone,"  "  ocuhsts,"  etc.  We 
shall  become  acquainted  with  some  excellent  men  among  these  old  mas- 
ters of  our  art.  Besides  the  above,  surgery  was  also  practised  by  the 
"  bathers,"  and  later  by  "  barbers  "  also,  as  it  was  among  the  Romans, 
and  they  were  permitted  by  law  to  attend  to  "  minor  surgery,"  e.  g., 
they  could  cup,  bleed,  treat  fractures,  sprains,  etc.  It  will  be  readily 
understood  that  some  strife  would  arise  about  the  various  and  some- 
times indefinite  privileges  of  these  diiferent  grades  of  physicians, 
especially  in  large  cities,  where  all  classes  of  them  were  collected. 
This  was  particularly  the  case  in  Paris.  The  surgical  society  there, 
the  "  College  de  St.  Come,"  claimed  the  same  privileges  as  members 
of  the  medical  faculty ;  they  were  particularly  desirous  for  the  Bacca- 
laureate and  Licentiate.  The  "  Society  of  Barbers  and  Bathers," 
again,  wished  to  practise  any  part  of  surgery,  just  like  the  members  of 
the  College  de  St.  Cotne.  To  gall  the  surgeons,  the  members  of  the  fac- 
ulty supported  the  claims  of  the  barbers,  and,  in  spite  of  mutual  tempo- 
rary compromises,  the  strife  continued ;  indeed,  we  may  say  that  it  still 
continues,  where  there  are  pure  surgeons  (surgeons  of  the  first  class 
and  barbers)  and  pure  physicians.  It  is  only  since  about  1850  that 
the  distinction  was  done  away  with  in  almost  all  the  German  states, 
and  neither  chirurgi  puri  nor  medici  purl  were  made,  but  only  physi- 
cians who  practised  medicine,  surgery,  and  obstetrics. 

To  finish  the  question  of  external  rank,  we  may  notice  that  in  Eng- 
land alone  there  is  still  a  tolerably  well-marked  dividing-Hne  be- 
tween surgeons  and  physicians,  especially  in  the  cities,  while  in  the 
country  "  general  practitioners  "  attend  to  both  medical  and  surgical 
cases,  and  have  an  apothecary-shop  even  at  the  same  time. 

In  Germany,  Switzerland,  and  France,  circumstances  often  cause  a 
physician  to  have  more  surgical  than  medical  practice ;  but  the  med- 
ical staff  legally  consists  of  physicians  and  assistants  or  barber-sur- 
geons, who,  after  examination,  are  licensed  to  cup,  bleed,  etc.  Tliis 
arrangement  has  finally  gone  into  effect  in  the  army  also,  where  the 
so-called  company  surgeon,  with  the  rank  of  sergeant,  formerly  had  a 
miserable  time  under  the  battalion  and  regimental  physicians. 


10  INTHODUCTION. 

In  again  taking  up  the  thread  of  the  historical  develoiomcnt  of 
surgery,  as  we  enter  the  period  of  "  Renaissance  "  in  the  sixteenth 
century,  we  must  first  think  of  the  great  change  which  then  took  place 
in  almost  all  sciences  and  arts,  on  account  of  the  Reformation,  the 
discovery  of  printing,  and  the  awakening  spirit  of  criticism.  Obser- 
vation of  Nature  began  to  reassume  its  proper  position  and  gradually 
but  slowly  to  free  itself  from  the  fetters  of  the  schools ;  investigation 
after  truth  again  assumed  its  claims  to  being  the  only  true  way  to 
knowledge — the  Hippocratic  spiiit  was  again  awakened.  It  was 
chiefly  tlie  new  investigations,  we  might  almost  say  the  rediscovery, 
of  anatomy  and  the  subsequent  restless  progress  of  this  branch,  that 
levelled  the  road.  V'esal  (1513-1564),  Falopia  (1523-1562),  zxi^Em- 
tachio  (f  1579),  were  the  founders  of  our  present  anatomy  ;  their  names, 
like  those  of  many  others,  are  known  to  you  from  the  appellations  of 
certain  parts  of  the  body.  The  celebrated  Bombastus  Theophrastus 
Paracelsus  (1493-1554)  was  among  the  first  to  criticise  the  prevailing 
Galenical  and  Arabic  systems,  and  to  claim  observation  as  the  chief 
source  of  medical  knowledge.  Finally,  when  William  Ilarvey 
(1578-1658)  discovered  the  circulation  of  the  blood,  end  Aselli  (1581- 
1626)  discovered  the  lymphatic  vessels,  the  old  anatomy  and  physiol- 
ogy were  obliged  to  give  place  to  modern  science,  which  thence  grad- 
ually progressed  to  our  times.  Even  then  it  Avas  a  long  time  before 
practical  medicine  escaped  in  the  same  way  fi'om  philosophic  thral- 
dom. System  was  founded  on  system,  and  the  theory  of  medicine 
constantly  varied  to  correspond  to  the  prevailing  philosophy.  We  may 
claim  that  it  was  not  till  pathological  anatomy  made  its  great  ad- 
vances in  the  present  century  that  practical  medicine  acquired  the 
firm  anatomico-physiological  foundation  on  which  the  whole  structure 
now  moves,  and  which  forms  a  strong  protection  against  all  philosoph- 
ical medical  systems.  Even  this  anatomical  direction,  however,  may  be 
pushed  too  far  and  too  exclusively.      We  shall  speak  of  this  hereafter 

Now  Ave  Avill  turn  our  attention  to  the  scientific  development  of 
surgery  from  the  sixteenth  century  to  our  times. 

It  is  an  interesting  feature  of  that  time  that  the  advance  of  practi- 
cal surgery  depended  more  on  the  surgical  societies  than  on  the 
learned  professors  of  the  universities.  German  surgeons  had  to  seek 
their  knowledge  mostly  in  foreign  universities,  but  part  of  it  the^ 
worked  out  for  themselves  independently  :  Heinrich  V07i  Pfohprundt^ 
a  German  friar  (born  the  beginning  of  the  fifteenth  century),  Illeron- 
ymiis  Brunschwig  (born  1430),  Hans  von  6^ers^or/' (about  1520),  and 
Felix  Wurtz  (f  1576),  surgeons  at  Basel,  are  first  among  these.  We 
have  Avritings  of  all  of  them ;  Felix  Wilrtz  seems  to  me  the  most 
original  of  them ;  he  had  a  sharp,  critical  mind,      Fahry  von  Hilden 


INTRODUCTION.  1 V 

(1560-1G34),  of  Berne,  and  Gottfried  Purman,  of  Halberstad  and 
Breslau  (about  1679),  were  men  of  great  acquirements ;  their  writ- 
ings show  a  high  appreciation  for  their  science,  they  fully  recognized 
the  value  and  imperative  necessity  of  exact  anatomical  knowledge, 
and  by  their  writings  and  private  instruction  imparted  it  to  their 
scholars  as  much  as  possible. 

Among  the  French  surgeons  of  the  sixteenth  and  seventeenth  cen- 
turies, Ambroise  Pare  (1517-1590)  is  most  prominent ;  originally  only 
a  barber,  from  his  great  services,  he  was  made  a  member  of  the  So- 
ciety of  St.  Come;  he  was  very  active  as  an  army  surgeon,  Avas  often 
called  from  home  on  consultations,  and  at  last  resided  in  Paris.  Pare 
advanced  surgery  by  what  was  for  those  times  a  very  sharp  criticism 
of  treatment,  especially  of  the  enormous  use  of  problematical  remedies ; 
some  of  his  treatises,  e.  g.,  on  the  treatment  of  gun-shot  wounds,  are 
perfectly  classical ;  he  rendered  himself  immortal  by  the  introduction  of 
Ugature  for  bleeding  vessels  after  amputation.  Pare,  as  the  reformer 
of  surgery,  may  be  placed  by  the  side  of  Vesal^  as  reformer  of  anatom3% 

The  works  of  the  above  individuals,  besides  some  others  more  or 
less  gifted,  held  their  place  into  the  seventeenth  century,  and  it  is 
only  in  the  eighteenth  that  we  find  any  important  advances.  The 
strife  between  the  members  of  the  faculty  and  those  of  the  College 
de  St.  Come  still  continued  in  Paris ;  the  great  celebrity  of  the  latter 
had  more  effect  than  the  professors  of  surgery.  This  was  finally  prac- 
tically acknowledged  in  1731  by  the  foundation  of  an  "Academy  of 
Surgery,"  which  was  in  all  respects  an  analogue  of  the  medical  faculty. 
This  institution  soon  advanced  to  such  a  point  that  it  ruled  the  sur- 
gery of  Europe  almost  a  century  ;  nor  was  this  an  isolated  cause  ;  it 
formed  part  of  the  general  French  influence,  of  that  universal  mental 
dominion  which  the  "  gTande  nation "  cannot  even  yet  forget  when 
German  science  has  forever  eclipsed  French  influence,  after  the  con- 
flicts of  1813-'14.  The  men  who  then  stood  at  the  head  of  the 
movement  in  surgical  science  were  Jean  Louis  Petit  (1674-17G8), 
Pierre  Jos.  Pesault  (1744-1795),  Pierre  Francois  Percy  (1754- 
1825),  and  many  others  in  France;  in  Italy,  Scarpa  (1748-1832)  was 
the  most  active.  Even  in  the  seventeenth  century,  surgery  was  highly 
developed  in  England,  and  in  the  eighteenth  century  it  attained  great 
eminence  under  Percival  Pott  (1713-1768),  William  and  JoJm 
Hunter  (1728-1793),  Benjamin  Bell  (1749-1806),  William  CJieseU 
den  (1688-1752),  Alexander  3Ionro  (1696-1767),  and  others. 
Among  these  was  John  Hunter,  that  great  genius,  as  celebrated 
for  anatomy  as  surgery ;  his  work  on  inflammation  and  Avounda 
still  forms  the  basis  of  many  of  our  present  views. 

In  comparison  with  these,  the  names  of  the  German  surgeons  of 


12  INTRODUCTION. 

the  eighteenth  century  are  insignificant ;  most  of  them  brought  thcii 
knowledge  from  Paris,  and  added  little  that  was  original :  Lorenz 
Heister  (1683-1758),  John  TJlrich  Bilguer  (1720-1796),  and  Ghr. 
Ant.  Theden  (1719-1797),  are  relatively  the  most  important.  Ger- 
man surgery  only  obtained  greater  eminence  wnth  the  commencement 
of  the  present  centur}^  Carl  Caspar  von  Siehold  (1736-1807),  and 
August  Gottloh  RicJiter  (1742-1812),  were  distinguished  men ;  the 
former  served  as  professor  of  surgery  in  Wurzbiirg,  the  latter  in  GOt- 
tino-en ;  some  of  Richter''s  writings  are  valuable  even  now,  especially 
his  little  book  on  rupture. 

On  the  threshold  of  our  century  j'ou  see  professors  of  surgery 
again  in  the  foreground,  where  they  subsequently  maintained  their 
position,  because  they  actually  practised  surgery.  A  predecessor  of 
old  Michter,  as  professor  of  surgery  at  Gottingen,  the  celebrated  Al- 
bert Haller  (1708-1777),  at  once  physiologist  and  poet,  one  of  the  last 
encyclopedists,  says,  "  Etsi  chirurgiae  cathedra  per  septemdecim  an- 
nos  mihi  concredita  fuit,  etsi  in  cadaveribus  dificilimas  administrationes 
cliirurgicas  frequenter  ostendi,  non  tamen  unquam  vivum  hominem 
incidere  sustinui,  nimis  ne  nocerem  veritus."  To  us  this  seems 
scarcely  credible,  so  great  is  the  change  "wrought  by  a  hundred  years. 
Even  at  the  commencement  of  this  century  the  French  surgeons  re- 
mained at  the  helm ;  Boyer  (1757-1833),  Belpech  (1776-1832),  and  ^^x- 
i[cu\a,r\y  Bupuytren  (1777-1835),  and  Jean  Dominique Barrey  (1776- 
1842),  were  almost  undisputed  authorities  in  their  line.  Besides  them 
there  arose  in  England  the  unimpeachable  authority,  Sir  Astley  Coop- 
er (1768-1841).  Larrey,  the  constant  companion  of  Napoleon  I., left  a 
large  number  of  works ;  you  will  hereafter  read  his  memoirs  with 
great  interest.  Bupuytren  was  chiefly  celebrated  for  his  excellent, 
clinical  lectures.  Cooper'^s  monographs  and  lectures  will  fill  you  with 
astonishment.  Translations  of  the  writings  of  the  above  French  and 
English  surgeons  first  aroused  German  surgery ;  but  soon  the  subject 
was  gone  into  most  profoundly  by  original  workers.  The  men  who 
induced  the  German  revolution  in  surgery  were,  among  others,  Vincenz 
von  Keryi^  of  Vienna  (1760-1829),  John  N'ep>.  Bust,  of  Berlin  (1775- 
1840),  Bhilipp  von  Walther,  of  Munich  (1782-1849),  Carl  Ferd.  von 
Graefe,  of  Berlin  (1787-1840),  Conr.  Joh.  Martin  BangenhecJc,  of 
Gottingen  (1776-1850),  Joh.  Friedrich  Bieffenhach  (1795-1847), 
Cajetan  von  Textor  (1782-1860),  of  Wurzburg. 

The  nearer  we  approach  the  middle  of  our  century,  the  more  the 
rugged  bounds  of  nationality  disappear  from  the  domains  of  surgery. 
With  increased  means  of  communication,  all  advances  in  science 
spread  with  breathless  haste  to  all  parts  of  the  civilized  world.  Num- 
berless writings,  national  and  international  medical  congressec,  and 


INTRODUCTION.  13 

personal  intercourse,  have  brought  radical  changes  to  the  surgeons  as 
well  as  to  others.  A  generation  of  surgeons,  upon  \yhose  works 
the  profession  looks  with  honor,  appears  to  be  now  dying  out ;  I 
mean  men  such  as  Stanley  (1791-18G2),  Lawrence  (1783-18G7),  and 
Brodie  (1783-1862),  in  England;  Roux  (1780-1854),  i?ow?ie;;  (1809- 
1858),  Leroy  (1798-1861),  Malgaigne  (1806-1865),  Civiale  (tl867), 
Jolert  (1799-1868),  and  Velpeau  (1795-1867),  in  France;  Seutin 
(1793-1862),  in  Belgium  ;  Valentme  3fott  (1785-1865),  in  America ; 
Wutzer  (1789-1863),  Schuh  (1804-1865),  and  others,  in  Germany. 
From  our  own  generation  also  we  have  some  losses  to  mourn,  espe- 
cially the  irreparable  death  of  the  gifted,  indefatigable  investigator 
0.  Weber  (1827-1867) ;  of  the  excellent  FolUn  (-1867),  one  of  the 
most  solid  of  modern  French  surgeons;  oi  Mlddeldorpf  (1824-1868), 
the  celebrated  inventor  of  galvano-caustic  operations.  Among  the 
living  we  might  name  many  on  whose  shoulders  rests  the  growing 
generation  of  German  surgeons,  but  they  do  not  yet  belong  to  his- 
tory. But  there  is  one  point  I  must  not  leave  unmentioned^  that  is,  the 
introduction  of  pain-quelling  remedies  into  surgery.  The  nineteenth 
century  may  be  proud  of  the  discovery  of  the  practical  use  of  sulphu- 
ric etlier  and  chloroform  as  angesthetics  in  all  sorts  of  operations.  In 
1846  came  from  Boston  the  first  news  that  3Iorton  the  dentist,  at  the 
suggestion  of  his  friend  Dr.  Jackson^  had,  in  extracting  teeth,  em- 
Dloyed  inhalations  of  sulphuric  ether,  pushed  to  complete  an;i3sthesia, 
with  perfect  success.  In  1859,  Simpson,  professor  of  obstetrics  in  Ed- 
inburgh, instead  of  ether,  introduced  in  surgical  practice  chloroform, 
which  acts  still  better,  which,  after  various  trials  Avith  other  similar 
substances,  still  preserves  its  reputation.  Thanks  !  in  the  name  of 
suffering  humanity,  a  thousand  thanks  to  these  men  ! 

In  continuation  of  my  previous  remarks  regarding  German  sur- 
gery, I  will  simply  add  that  at  present  it  stands  at  least  equal  to  that 
of  other  nations,  and  is  perhaps  even  superior  to  that  of  France  at  the 
present  time.  To  perfect  ourselves  in  the  science  of  sui-gery,  we  no 
longer  need  to  visit  Paris.  But,  of  course,  it  is  nevertheless  desirable 
for  every  physician  to  enlarge  his  experience  and  observation  by  visit- 
ing foreign  lands.  In  the  scientific  as  well  as  in  the  practical  part  of 
surgery,  and  of  medicine  generally,  England  is  now  more  advanced 
than  any  other  country.  In  America  also  great  advances  have  been 
made  in  practical  surgery.  From  the  time  of  Hunter  to  the  present 
day,  English  surgery  has  about  it  something  noble.  Surgery  owes 
its  great  revolution  in  the  nineteenth  century  to  its  attempt  to  unite 
all  medical  knowledge  in  itself ;  the  surgeon  who  succeeds  in  this,  and 
also  masters  the  entire  mechanical  side  of  the  art,  may  feel  that  he 
Las  attained  the  highest  ideal  in  medicine. 


£4  IXTRODUCTIOX. 

Before  entering  on  oiir  subject,  I  will  add  a  few  remarks  about 
the  study  of  surgery  as  it  is,  or  is  said  to  be,  pursued  in  our  high- 

BCllOols. 

In  the  four  years'  course  of  medical  study  which  is  customary  in 
German  universities,  I  would  advise  you  not  to  begin  surgery  before 
the  fifth  semestre.  You  often  desire  to  escape  the  preliminary  studies 
and  plunge  at  once  into  the  practical.  It  is  true,  this  is  somewhat 
less  the  case  since  courses  on  anatomy,  microscopy,  physiology,  chem- 
istry, etc.,  have  been  started  in  the  high-schools,  where  you  have  some 
practice ;  nevertheless,  there  is  still  too  much  haste  to  enter  the  clin 
ics.  It  is  true,  it  is  one  way  of  gaining  experience  from  the  very  start ; 
vou  consider  it  more  interesting  than  bothering  yourselves  at  first 
with  things  whose  connection  with  practice  you  do  not  exactly  un- 
derstand. But  you  forget  that  a  certain  school  of  observation  must 
be  gone  through  with,  to  enable  us  to  make  actually  useful  what  w^e 
know.  If  any  one  just  released  from  school  should  at  once  enter 
the  hospital  as  a  student,  he  would  be  in  tlie  same  position  as  a  child 
entering  the  world  to  collect  knowledge.  Of  Avhat  use  are  the  ex- 
periences of  the  child  for  his  subsequent  life  among  men  ?  How  late 
it  is  before  we  see  the  true  use  of  the  most  common  observations  of 
dailv  life  !  Hence,  to  wade  through  the  entire  development  of  medi- 
cine in  this  empirical  manner  would  be  a  long,  tedious  labor,  and  only 
a  very  gifted,  industrious  man  would  learn  any  thing  in  this  way. 
After  having  made  numerous  errors,  we  must  not  place  too  great  a 
value  on  "experience"  and  "observation,"  if  by  these  terms  we  mean 
no  more  than  the  laity  do.  It  is  an  art,  a  talent,  a  science,  to  observe 
criticallv,  and  from  our  observations  to  draw  correct  conclusions  for 
our  "  experience  ; "  this  is  the  strong  point  of  the  empiric  ;  the  laity 
know  experience  and  observation  in  the  vulgar,  not  in  the  scientific 
sense,  and  the}'  value  the  so-called  experience  of  an  old  shepherd  as 
high  as,  sometimes  higher  than,  that  of  a  physician ;  unfortunately, 
the  public  are  sometimes  right  on  this  point.  But  enough  !  when  a 
physician  or  any  one  else  displays  his  experience  and  observation  be- 
fore you,  look  sharply  to  see  whether  he  has  any  brains. 

In  making  these  remarks  against  pure  empiricism,  we  do  not  by 
any  means  intend  to  say  that  you  must  be  theoretically  acquainted 
with  all  medicine  before  studying  it  practically,  but  you  should  bring 
a  certain  knowledge  of  the  fundamental  principles  of  natural  science 
with  you  into  the  clinic.  It  is  absolutely  necessary  to  have  a  general 
idea  of  what  you  are  to  expect ;  and  you  must  know  something  of 
the  tools  before  seeing  them  used,  or  taking  them  in  your  hands.  In 
other  words,  you  should  know  the  outlines  of  general  pathology  and 
therapeutics,  as  well  as  of  materia  medica,  before  going  to  the  bed- 


INTRODCrCTIOX.  15 

ride  of  the  patient.  General  svu-gery  is  only  one  part  of  general 
pathology,  hence  you  should  study  the  latter  before  entering  the  sur- 
gical clinic.  First,  you  should  gain  a  clear  understanding  of  normal 
histology,  at  least  of  its  general  parts ;  pathological  anatomy  and 
histology  should  come  with  general  surgery,  about  the  fifth  semestre. 

General  sui'gery,  the  subject  of  the  present  lectures,  is  a  part  of 
general  pathology,  as  we  have  already  stated  ;  but  it  is  nearer  to 
practice  than  the  latter.  It  comprises  the  study  of  wounds,  inflam- 
mations, and  tumors  of  the  external  parts  of  the  body,  or  of  those 
parts  that  may  be  handled  from  without.  Special  or  topographical 
surgery  occupies  itself  with  the  surgical  diseases  of  different  parts  of 
the  body,  so  that  the  most  different  tissues  and  organs  are  to  be  con- 
sidered according  to  their  location ;  for  instance,  while  we  here  treat 
only  of  wounds,  of  their  mode  of  recovery  and  treatment  in  general, 
special  surgery  treats  of  wounds  of  the  head,  breast,  and  abdomen, 
paying  special  attention  to  the  participation  of  the  skin,  bones, 
and  viscera.  Were  it  possible  to  pursue  the  study  of  surgery  for 
several  years  in  a  large  hospital,  and  could  careful  clinical  consid- 
eration of  individual  cases  l^e  earned  on  continuously  wuth  the  regular 
studies,  it  Avould  probably  be  unnecessary  to  treat  of  special  surgery 
in  separate  systematic  lectures.  But,  since  there  are  many  surgical  dis- 
eases that  perhaps  may  not  occur  for  years  even  in  a  large  hospital, 
but  which  should  be  known  to  the  surgeon,  the  lectures  on  special 
surgery  are  by  no  means  superfluous,  if  they  are  short  and  to  the  point. 

During  my  student  days  I  occasionally  heard  the  remark  :  "  AVhy 
should  I  go  to  listen  to  special  surgery  and  pathology  ?  I  can  read 
them  more  conveniently  in  my  room."  This  may  be  all  true,  but  un- 
fortunately it  is  rarely  done,  unless  in  the  final  semestres,  when  exam- 
ination is  approaching.  This  reasoning  is  false  in  another  respect 
also :  the  viva  vox  of  the  teacher,  as  old  LangenbecJc,  in  Gottingen^ 
used  to  say  (and  he  had  a  viva  vox  in  the  best  sense  of  the  word), 
the  winged  word  of  the  teacher  is,  or  should  be,  more  exciting  and 
effective  than  what  is  read,  and  the  accompanying  demonstrations 
of  diagrams,  preparations,  experiments,  etc.,  should  render  the  lectures 
on  practical  surgery  and  medicine  particularly  valuable  for  you.  I 
attach  great  value  to  demonstration  in  medical  instruction,  for  I  know 
by  experience  that  this  kind  of  teaching  is  most  exciting  and  per- 
manent. 

Besides  these  two  sets  of  lectures  on  general  and  special  svn-gery 
you  have  to  practise  operations  on  the  cadaver ;  this  you  may  post- 
pone to  the  last  semestres.  I  always  like  students  to  take  their 
course  in  operations  in  the  sixth  or  seventh  semestres,  along  with 
their  s[)ecial  surgery,  so  that  I  may  give  them  the  opportunitv  of  oo 


10 


INTRODUCTION. 


casionally  operating,  or  even  of  amputating,  under  my  direction.  It 
gives  courage  in  practice,  if  one  has  during  student-life  performed  op- 
erations on  tlie  living  subject.  When  you  have  followed  the  lecture? 
on  general  surgery,  you  may  enter  the  surgical  clinic,  and  there,  in 
the  seventh  and  eighth  semestres,  openly  give  an  account  of  your 
knowledge  in  special  cases,  and  accustom  yourselves  to  collecting 
your  ideas  rapidly,  learn  to  distinguish  the  important  from  the  imim- 
portant,  and  to  learn  generally  in  what  practice  really  consists.  You 
will  thus  learn  the  points  where  your  knowledge  is  deficient,  and  may 
perfect  yourselves  by  persevering  study.  When  you  have  thus  com- 
pleted the  legal  time  of  your  studies,  passed  your  examination,  and 
have  increased  your  medical  knowledge  by  a  few  months  or  a  year  in 
various  large  hospitals  at  home  or  abroad,  you  will  be  in  condition  to 
appreciate  the  surgical  cases  turning  up  in  practice.  But,  if  you  wish 
to  devote  special  attention  to  surgery  and  operating,  you  are  still 
far  from  the  goal :  then  you  must  become  accustomed  to  operating  on 
the  cadaver,  enter  a  surgical  ward  as  assistant  for  a  year  or  two,  un- 
tiringly study  monographs  on  surgical  subjects,  perseveringly  write 
out  cases,  etc. — in  short,  follow  out  the  practical  school  from  the  lowest 
step.  You  must  be  fully  acquainted  with  hospital  service,  even  with 
the  duties  of  the  nurses ;  in  short,  you  should  know  practically  even 
the  most  minute  things  appertaining  to  the  care  of  patients,  and 
should  even  perform  the  duties  yourselves  occasionally,  so  that  you 
may  be  fully  master  of  the  entire  medical  service  intrusted  to  you. 

You  see  there  is  much  to  do  and  to  learn  :  with  patience  and  perse- 
verance you  will  accomplish  it  all ;  but  these  virtues  are  necessary  to 
the  study  of  medicine. 

"  Student  "  comes  from  "  to  study  ;  "  hence  you  must  study  faith- 
fully ;  the  teacher  indicates  to  you  what  he  considers  the  most  impor- 
tant ;  he  may  stimulate  you  in  various  directions ;  what  he  gives  you 
as  positive  may,  it  is  true,  be  carried  home  in  black  and  white,  but,  to 
cause  this  positive  knowledge  to  live  in  you  and  become  your  mental 
property,  you  must  depend  on  your  own  mental  efforts,  which  form  the 
true  "  study." 

When  you  conduct  yourself  as  a  passive  receptacle,  you  may,  it 
is  true,  acquire  the  name  of  a  very  "  learned  person,"  but,  if  you  do 
not  awake  your  knowledge  into  life,  you  will  never  become  a  good 
"  practising  physician."  Let  what  you  see  enter  your  mind  fully, 
warm  you  up,  and  so  occupy  your  attention  that  you  must  think  of  it 
frequently,  then  the  true  pleasure  and  appreciation  of  this  mental 
labor  will  fill  you.  Goethe,  in  a  letter  to  Schiller,  aptly  says  :  "  Pleas- 
ure, comfort,  and  interest  in  the  affairs  of  life,  are  the  only  realities 
all  else  is  vanity  and  disappointment." 


CHAPTER  I. 
SIMPLE  IlSrCISEI)  WOUJS'DS  OF  THE  SOFT  PARTS, 


LECTURE   II, 


M  ode  of  Origin  and  Appearance  of  these  "Wounds. — Various  Forms  of  Incised  Wounds, 
— Appearance  during  and  immediately  after  tlieir  Occurrence. — Pain,  Bleeding. — 
Varieties  of  Hasmorrhage ;  Arterial,  Venous. — Entrance  of  Air  through  Wounded 
Veins. — Parenchymatous  Hsemori'hage. — Ha;morrhagic  Diathesis. — Haemorrhage 
from  the  Pharynx  and  Kectum. — Constitutional  Effects  of  Severe  Haemorrhage. 

The  propel'  treatment  of  wounds  is  to  be  regarded  as  the  most 
important  requirement  for  the  surgeon,  not  only  on  account  of  the 
frequency  of  this  variety  of  injury,  but  because  we  so  often  inten- 
tionally make  them  in  operating,  even  when  operating  for  something 
that  is  not  itself  dangerous  to  life.  Hence  we  are  answerable  for  the 
healing  of  the  wound,  to  as  great  an  extent  as  it  is  possible  by  expe- 
rience to  judge  of  the  danger  of  an  injury.  Let  us  commence  with 
incised  wounds. 

Injuries  caused  by  sharp  knives,  scissors,  sabres,  cleavers,  hatchets, 
etc.,  represent  pure  incised  wounds.  Such  wounds  are  usually  recog- 
nizable by  the  regular  sharp  borders,  where  we  see  the  smooth-cut 
surface  of  the  unchanged  tissue ;  should  the  instruments  be  blunt,  by 
very  rajDid  motion  they  may  still  cause  quite  a  smooth  incised  wound, 
while  by  slowly  entering  the  tissue  they  would  give  the  edges  of  the 
wound  a  ragged  appearance ;  occasionally,  the  variety  of  the  injury 
does  not  become  evident  till  the  wound  is  healing,  for  wounds  made 
vrith  sharp  instruments  heal  more  readily  and  quickly  (for  reasons  to 
be  given  hereafter)  than  those  caused  by  the  slow  entrance  of  dull 
knives,  scissors,  etc. 

Rarely  a  perfectly  blunt  body  makes  a  v*'Ound  exactly  like  an  incised 
one.     This  may  occur  from  the  skin  being  torn  through  by  force  ap- 
plied through  a  blunt  object,  at  a  point  where  it  lies  over  the  bone. 
Thus  you  will  not  unfrequently  see  scalp-wounds  resembling  incised 
3 


18  SIMPLE   INCISED  WOUNDS   OF  THE   SOFT   PARTS. 

wounds,  altliougli  tliey  may  have  been  clue  to  a  blow  from  a  blunt  body, 
or  from  striking  the  head  against  a  stone,  beam,  etc. ;  similar  smooth 
wounds  of  the  skin  also  occur  on  the  hand,  especially  on  the  volar  sur- 
face. Sharp  angles  of  bone  may  so  di^dde  the  skin  from  within  that 
it  will  look  as  if  cut  through,  as,  for  instance,  when  one  falls  on 
the  crest  of  the  tibia,  and  it  divides  the  skin  from  within  outward. 
As  may  be  readily  understood,  sharp  sj^linters  of  bone  perforating  the 
skin  may  also  make  wounds  with  smooth  surfaces.  Lastly,  the  open- 
ing of  exit  of  a  bullet-wound,  i.  e.,  of  the  canal  which  represents  the 
passage  of  a  bullet,  may  sometimes  be  a  sharp  slit. 

The  knowledge  of  these  points  is  important,  for  a  judge  may  ask 
you  if  a  wound  has  been  caused  by  this  or  that  instrument,  in  this  or 
that  manner,  points  which  may  greatly  affect  the  bearings  in  a  crimi- 
nal suit. 

Hitherto  we  have  only  ccmsidered  wounds  made  Mith  a  blow  or 
stroke.  But,  by  repeated  cuts  on  a  wound,  the  edges  may  acquire  a 
hacked  appearance,  and  thus  the  requirements  for  recovery  may  be 
very  much  changed.  For  the  present,  we  leave  such  wounds  out  of 
consideration ;  their  mode  of  recovery  and  treatment  is  just  the  same 
as  that  in  contused  wounds,  unless  they  can  be  artificially  converted 
into  simple  incised  wounds  by  paring  off  the  jagged  edges.  The 
various  directions  in  which  the  cutting  instrument  enters  the  body 
generally  makes  little  difference,  unless  the  direction  be  so  oblique 
that  some  of  the  soft  parts  are  detached  in  the  form  of  a  more  or  less 
thick  flap.  Tn  these  j^c(/> wounds,  the  width  of  the  bridge,  uniting  the 
half-separated  portion  Avith  the  body,  is  important,  because  on  this 
depends  the  question  as  to  whether  circulation  of  blood  can  continue 
in  this  flap,  or  if  it  has  ceased,  and  the  detached  portion  is  to  be  re- 
garded as  dead.  Flap-wounds  are  chiefly  due  to  cuts,  but  may  also 
arise  from  tearing ;  they  are  very  frequent  in  the  head,  where  part  of 
the  scalp  is  torn  off  by  a  hard  blow.  In  other  cases  a  portion  of  the 
soft  parts  may  be  entirely  cut  out ;  then  we  have  a  wound  with  loss  q/ 
substance. 

Hy  penetratbiff  icounds  we  mean  those  by  which  one  of  the  three 
great  ca^dties  of  the  body  or  a  joint  is  opened ;  they  are  most  fre- 
quently due  to  stabs  or  gun-shot  injuries,  and  may  be  complicated  by 
wounds  of  the  viscera  or  bones.  By  the  general  terms  longitudinal 
and  diagonal  wounds  we  of  course  mean  those  corresponding  to  the  long 
or  diagonal  axes  of  the  trunk,  head,  or  extremities.  Diagonal  or  longi- 
tudinal wounds  of  the  muscles,  tendons,  vessels,  or  nerves,  are  of  course 
those  dividing  these  parts  longitudinally  or  diagonally.  The  syrnp 
toms  in  the  person  wounded,  induced  more  or  less  directly  by  the 
wound,  are,  first, /Ja«?i/  then,  bleeding  and  gaping  of  the  wound. 


SYMPTOMS— PAIN.  19 

As  all  the  tissues,  not  excepting  the  epithelial  and  epidermoid, 
Are  supplied  with  sensory  nerves,  injury  at  once  causes  pain. 

This  pain  varies  greatly  with  the  nerve-supply  of  the  wounded 
part,  and  with  the  sensitiveness  of  the  patient  to  pain.  The  most 
sensitive  parts  are  the  fingers,  lips,  tongue,  nipples,  external  genitals, 
and  about  the  anus.  Doubtless,  each  of  you  knows  from  experience 
the  character  of  the  pain  from  a  wound,  as  of  the  finger.  The  division 
of  the  skin  is  the  most  painful  part ;  injury  of  the  muscles  and  ten- 
dons is  far  less  so  ;  injury  of  the  bone  is  always  very  painful,  as  you  may 
find  from  any  one  that  has  recovered  from  a  fracture;  it  has  also  been 
handed  down  to  us  from  the  times  when  amputations  were  made  with- 
out chloroform,  that  sawing  the  bone  was  the  most  painful  part  of  the 
operation.  The  mucous  membrane  of  the  intestines,  on  being  irri- 
tated in  various  ways,  shows  very  little  sensitiveness,  as  has  been  occa- 
sionally observed  on  man  and  beast ;  the  vaginal  portion  of  the  ute- 
rus also  is  almost  insensitive  to  mechanical  and  chemical  irritation ; 
occasionally,  it  may  be  touched  with  the  hot  iron,  as  is  done  in  treat- 
ing certain  diseases  of  this  part,  without  its  being  felt  by  the  patient. 
It  appears  that  the  nerves  requiring  a  specific  irritation,  as  the 
nerves  of  special  sense,  are  accompanied  by  few  if  any  sensor}' 
fibres.  The  relation  of  the  sensory  nerves  of  touch  to  the  sentient 
nerves  in  the  skin  cannot  be  regarded  as  decided,  or  whether  there 
be  any  decided  difference  between  them.  In  the  nose  and  tongue,  we 
have  sensory  and  sentient  nerves  close  together,  so  that  in  both  parts, 
besides  the  specific  sense  peculiar  to  the  organ,  pain  may  also  be  per- 
ceived. The  white  substance  of  the  brain,  although  containing  many 
nerves,  is  without  feeling,  as  may  be  seen  in  many  severe  injuries  of 
the  head.  The  division  of  nerve-trunks  is  the  severest  of  all  inju- 
ries. Some  of  you  may  remember  the  pain  from  rupture  of  a  dental 
nerve  on  extraction  of  a  tooth.  Severing  of  thick  nerve-trunks  must 
cause  overpowering  pains.  Sensitiveness  to  pain  appears  peculiar  to 
individuals.  But  you  must  not  confound  this  Avith  various  exhibitions 
of  pain,  and  with  the  psychical  power  of  suppressing,  or  at  least  limiting, 
tliis  exhibition ;  the  latter  depends  on  the  strength  of  will,  as  well  as 
on  the  temperament,  of  the  individual.  Vivacious  persons  display  their 
pain,  as  well  as  their  other  feelings,  more  than  phlegmatic  pei'sons. 
Most  persons  maintain  that  crying,  as  well  as  the  instinctive  powerful 
tension  of  all  the  muscles,  especially  of  the  masseters,  gritting  the 
teeth,  etc.,  renders  the  pain  more  endurable.  Personally,  I  have  not 
been  able  to  verify  this  statement,  and  I  think  it  must  be  a  mistake 
of  the  patients.  Strong  will  in  the  patient  may  do  much  to  suppress 
the  show  of  pain.  I  Avell  remember  a  woman  in  the  Gottingen  clinic, 
when  I  was  a  student,  wdio,  without  chloroform,  had  the  whole  uppei 


20 


SIMPLE   INCISED    WOUNDS    OF    THE    SOFT    PARTS. 


jaw  removed  for  a  malignant  tumor,  and,  during  this  difficult  and 
painful  operation,  she  did  not  once  cry  out,  although  several  branches 
of  the  trifacial  nerve  were  divided.  Women  generally  stand  suffer- 
ing better  and  more  patiently  than  men.  But  the  necessary  exercise 
of  psychical  strength  not  uiifrequently  causes  subsequent  fainting,  or 
excessive  physical  and  psychical  relaxation,  of  longer  or  shorter  du- 
ration. You  will  certainly  meet  persons  who,  without  any  exercise 
of  will,  show  so  little  pain  from  severe  injury  that  we  can  only  be- 
lieve that  they  really  feel  pain  less  acutely  than  others ;  I  have  ob- 
served this  most  in  flabby  sailors,  in  whom  all  the  sequelse  of  the 
injury  are  also  generally  very  insignificant. 

The  quicker  the  wound  is  made,  and  the  sharper  the  knife,  the 
less  the  pain  ;  hence,  in  large  and  small  operations,  it  has  always 
seemed,  and  very  correctly  too,  for  the  advantage  of  the  patient, 
that  the  incisions  should  be  made  with  certainty  and  rapidity,  par- 
ticularly in  dividhig  the  skin. 

The  feeling  in  the  wound,  immediately  after  its  reception,  is  a 
peculiar  burning.  It  can  scarcely  be  termed  any  thing  but  the  feel- 
ing of  being  wounded  ;  there  are  a  number  of  provincialisms  for  it — 
in  Northern  Germany,  for  instance,  they  say  "  the  wound  smarts." 
Only  when  a  nerve  is  compressed  by  something  in  the  wound,  twisted 
or  irritated  in  some  way,  there  are  severe  neuralgic  pains  immedi- 
ately after  the  injury ;  if  these  do  not  soon  cease  spontaneously,  or 
after  examination  of  the  wound  and  removal  of  the  local  cause,  if 
possible,  they  should  be  arrested  by  the  exhibition  of  some  internal 
remedy  ;  otherwise,  they  will  induce  and  keep  up  a  state  of  excite- 
ment in  the  patient  that  may  increase  to  maniacal  delirium. 

To  avoid  the  2}ciin  in  operations^  we  now  always  use  anaesthet- 
ics ;  this  subject  will  be  treated  of  in  the  course  on  operations. 
Recently  ether  has  come  more  into  use  on  account  of  the  number  of 
deaths  from  chloroform.  I  now  use  a  composition  of  3  parts  chloro- 
form, 1  sulphuric  ether,  and  1  absolute  alcohol,  which  seems  less 
dangerous  than  chloroform  alone.  In  England,  for  some  years, 
Spencer  Wells,  among  others,  has  used  and  recommended  bichloride 
of  methyline,  claiming  that  it  acts  as  quickly  as,  and  is  less  dan- 
gerous than,  chloroform.  Local  anmsthetics,  which  have  for  their 
object  temporary  blunting  of  the  pain  in  the  part  to  be  operated 
on,  by  application  of  a  mixture  of  ice  and  saltpetre,  or  salt,  have 
been  again  abandoned,  or  rather  they  have  never  been  generally 
received.  Recently  these  attempts  have  again  acquired  a  general 
interest,  as  it  seemed  that  a  suitable  method  of  local  anaesthesia  had  at 
last  been  found.  An  English  physician,  Richardson,  constructed  a 
small  apparatus,  by  which  a  stream  of  pure  ether  [or,  better,  rhigo- 


SYMPTOMS— HAEMORRHAGE.  21 

line]  spray  is  for  a  time  blown  against  one  spot  in  the  skin,  and 
eucli  cold  is  here  induced  that  all' sensation  is  lost.  After  procuring 
some  of  this  ether  (hydramyliither)  from  England,  I  was  satisfied  of 
its  perfect  action.  In  a  few  seconds  the  skin  becomes  chalky  white, 
and  absolutely  without  sensation  ;  but  the  effect  hardly  extends 
through  a  moderately  thick  cutis ;  and,  if  the  ether  be  still  blown 
against  the  cut  surface,  the  frozen  tissues  cannot  be  distinguished 
from  each  other,  and  the  knife,  being  coated  with  ice,  will  no  longe? 
cut.  Hence,  even  in  this  more  perfect  form,  local  anfesthesia  can 
only  be  used  advantageously  in  a  few  minor  operations.  My  former 
dread,  that  healing  of  the  wound  would  be  essentially  interfered  with 
by  this  freezing  of  the  part,  has  been  shown  by  experience  to  be 
groundless.  For  quelling  the  joain,  and  as  a  hypnotic,  immediately 
after  extensive  injuries  or  operations,  there  is  nothing  better  than  a 
quarter  of  a  grain  of  muriate  or  acetate  of  morphia ;  this  quiets  the 
patient,  and,  even  if  it  does  not  make  him  sleep,  he  feels  less  pain 
from  his  wound.  Quite  recently  hydrate  of  chloral  (  3  ss-  3  j,  in  half 
a  glass  of  water)  has  been  used ;  its  narcotic  action  was  discovered 
by  Liehreich,  1869.  Its  effect  is  essentially  hypnotic,  but  very  uncer- 
tain ;  it  cannot  supplant  chloroform,  but  is  a  decided  acquisition  to 
our  materia  medica.  Locally,  for  the  relief  of  pain,  we  employ  cold 
in  the  shape  of  cold  compresses,  or  bladders  filled  with  ice,  applied 
to  the  wound.  We  shall  refer  to  this  under  the  treatment  of  wounds. 
Lastly,  we  ma\'  give  hypodermic  injections.  If,  with  a  very  fine 
syringe,  furnished  with  a  lance-shaped,  sharp  canula,  which  may  be 
thrust  readily  through  the  skin,  we  inject  a  solution  of  •^— j  of  a  grain 
of  acetate  or  muriate  of  morphia,  this  remedy  will  exercise  its  nar- 
cotic effect  at  first  locally  on  the  nerves  it  comes  in  contact  with,  and 
then  on  the  brain,  as  the  solution  is  absorbed  and  enters  the  blood. 
Of  late,  this  mode  of  employing  morphia  has-been  exceedingly  popu- 
lar; immediately  after  an  operation,  or  severe  injury,  such  an  injec- 
tion is  given,  and  the  pain  is  at  once  arrested. 


In  a  pure  incised  or  punctured  wound,  hcetnorrhage  is  another  im- 
mediate symptom ;  its  extent  depends  on  the  number,  size,  and  variety 
of  the  divided  vessels.  At  present  we  shall  only  speak  of  haemorrhage 
from  tissues  previously  normal,  and  distinguish  capillary,  parenchyma- 
tous, arterial,  and  venous  hcemorrhages,  which  must  be  considered  sep- 
arately. 

As  is  well  known,  the  different  parts  of  the  body  vary  greatly  in 
vascularity,  especially  in  the  number  and  size  of  the  capillaries.  In 
spots  of  equal  size  the  skin  has  fewer  and  smaller  capillaries  than  most 


22  SIMPLE   INCISED  WOUNDS   OF   THE   SOFT   PARTS. 

mucous  membranes ;  it  also  lias  more  elastic  tissue  and  muscles,  by 
-.vhich  (as  we  may  feel  and  see  in  the  cold  and  so-called  goose-flesh) 
the  vessels  are  more  readily  compressed  than  they  are  in  the  mucoua 
membranes,  which  are  poor  in  elastic  and  muscular  tissue ;  hence  simple 
skin-wouids  bleed  less  than  those  in  mucous  membranes.  Hemor- 
rhages from  the  capillaries  alone  cease  spontaneously  if  the  tissue  be 
healthy,  because  the  openings  of  the  vessels  are  compressed  by  con- 
traction of  the  wounded  tissue.  In  diseased  parts,  which  do  not  con- 
tract, even  haemorrhage  from  dilated  capillaries  may  be  very  consider- 
able. 

Ha3morrhage  from  the  arteries  is  readily  recognized,  on  the  one 
hand,  because  the  blood  flows  in  a  stream,  which  sometimes  clearly 
shows  the  rhythmical  contractions  of  the  heart ;  on  the  other,  by  the 
bright-red  color  of  the  blood.  If  there  be  impaired  respiration,  this 
bright-red  color  may  change  to  a  dark  hue  ;  thus,  in  operations  on  the 
neck,  performed  to  prevent  threatening  suffocation,  and  in  deep  anaes- 
thesia, dark  or  almost  black  blood  may  spm-t  from  the  arteries.  The 
amount  of  blood  escaping  depends  on  the  diameter  of  the  totally- 
divided  artery,  or  on  the  size  of  the  opening  in  its  wall.  You  must 
not,  however,  believe  that  the  stream  of  blood  corresponds  exactly  to 
the  size  of  the  artery  ;  it  is  usually  much  smaller,  for  the  calibre  of 
the  artery  generally  contracts  at  the  point  of  division ;  only  the 
larger  arteries,  such  as  the  aorta,  carotids,  femoral,  axillary,  etc.,  have 
so  little  muscular  fibre  that  they  contract,  in  their  circumference  at 
least,  to  a  scarcely  perceptible  extent.  In  very  small  arteries,  this  con- 
traction of  the  cut  vessel  has  such  an  effect  that,  from  the  increased 
friction,  the  blood  flows  from  them  without  spurting  or  pulsating ;  in- 
deed, in  very  small  arteries,  this  friction  may  be  so  decided  that  the 
blood  flows  with  diflBculty  and  very  slowly,  and  soon  coagulates,  so 
that  the  hceraorrhage  is  arrested  spontaneouslj^  The  smaller  the 
diameter  of  the  arteries  becomes,  from  diminution  of  the  amount  of 
blood  in  the  body,  the  more  readily  haemorrhage  wiU  be  arrested  spon- 
taneously, while  otherAvise  it  would  have  to  be  arrested  artificially. 
Hereafter,  you  will  often  have  occasion  to  see  in  the  chnic  how  freely 
the  blood  spurts  at  the  commencement  of  an  operation,  and  how  much 
less  it  will  be  toward  the  end,  even  when  we  cut  larger  vessels  than 
were  at  first  divided.  Thus  decrease  of  the  total  volume  of  blood  may 
cause  spontaneous  arrest  of  haemorrhage  ;  the  weaker  contractions  of 
the  heart  have  also  some  influence  in  this.  Indeed,  in  internal  haemor- 
rhages that  we  cannot  reach  directly,  we  employ  rapid  abstraction  of 
blood  from  the  arm  (venesection)  as  a  haemostatic ;  in  such  cases  the 
artificial  excitement  of  ansemia  is  not  unfrequently  the  only  remedy 
we  have  for  internal  haemorrhage,  paradoxical  as  this  may  seem   to 


SYMPTOMS— HEMORRHAGE.  28 

you  at  the  first  glance.  Hferaorrhages  from  incised  wounds  of  the 
large  arteries  of  the  trunk,  neck,  and  extremities,  are  always  so  con- 
siderable that  they  absolutely  require  to  be  arrested,  unless  the  open- 
ings in  their  walls  be  very  small.  But,  when  the  terminal  branch  of 
an  artery  is  ruptured  without  a  wound  of  the  skin,  the  hasmorrhage 
may  be  arrested  by  pressvire  on  the  surrounding  soft  parts ;  such  in- 
jui'ies  subsequently  induce  other  changes,  to  which  your  attention 
will  be  called  under  other  circumstances. 

HEemorrhage  from  the  veins  is  characterized  by  the  steady  flow  of 
dark  blood.  This  is  especially  true  of  small  and  middle-sized  veins. 
These  hgemorrhages  are  rarely  very  profuse,  so  that,  in  order  to  obtain 
a  sufficient  quantity  on  letting  blood  from  the  subcutaneous  veins  of 
the  arm  at  the  bend  of  the  elbow,  we  must  obstruct  the  flow  of  blood 
to  the  heart.  If  this  were  not  done,  blood  would  only  flow  from  this 
vein  at  the  time  of  puncture,  further  haemorrhage  would  cease  sponta- 
neously, imless  kept  up  by  muscular  contractions.  This  is  chiefly  be- 
cause the  thin  walls  of  the  veins  collapse,  instead  of  gaping,  as  the 
arteries  do  when  divided.  Blood  does  not  readily  flow  back  from  the 
central  end  of  the  vein,  on  account  of  the  valves  ;  we  rarely  have  any 
thing  to  do  with  the  valveless  veins  of  the  portal  system. 

Hemorrhage  from  the  large  venous  trunks  is  always  a  dangerous 
symptom.  Bleeding  from  the  axillary,  femoral,  subclavian  or  inter- 
nal jugular,  is  usually  quickly  fatal,  unless  aid  arrive  immediately ; 
wounds  of  the  vena  anonyma  may  be  regarded  as  absolutely  mortal. 
The  blood  does  not  flow  continuously  from  these  large  veins,  but  the 
flow  is  greatlj'  influenced  by  the  respiration.  In  operations  about 
the  neck  I  have  frequently  seen  patients  live  after  their  internal  jug- 
ular vein  had  been  woimded ;  during  inspiration  the  vessel  collapsed 
so  that  it  might  have  been  regarded  as  a  connective  tissue  string ; 
during  expiration  the  black  blood  gushed  up  as  from  a  well,  or  still 
more  like  the  bubbling  up  of  the  water  from  a  deep  spring. 

In  these  veins  near  the  heart,  besides  the  rapid  loss  of  blood,  there 
is  another  element  that  greatly  increases  the  danger ;  this  is  the  en- 
trance of  air  into  the  veins  and  heart,  as  occasionally  takes  place  with 
a  gurgling  noise,  on  deep  inspiration,  when  the  blood  rushes  toward 
the  heart ;  this  may  cause  instant  death,  though  not  necessarily.  I 
cannot  now  enter  more  explicitly  into  this  very  remarkable  phenom- 
enon, whose  physiological  eff"ect  has  not,  as  it  seems  to  me,  been  sat- 
isfactorily explained ;  you  will  again  have  your  attention  called  to 
this  subject  by  the  books  and  lectures  on  operative  surgery.  I  shall 
merely  mention  that,  on  opening  one  of  the  large  veins  of  the  neck  or 
the  axillary  vein,  there  may  be  a  perceptible  gurgling  sound ;  the 
patient  instantly  loses  consciousness,  and  can  rarely  be  restored  to 


•24  SIMPLE    INCISED  WOUNDS  OF  THE   SOFT   PARTS. 

life  by  instantaneous  resort  to  artificial  respiration,  etc.  Death  is 
probably  caused  by  the  entrance  of  air-bubbles,  which  press  forward 
into  the  medium-sized  pulmonary  arteries,  and  are  there  arrested,  and 
prevent  further  access  of  blood  to  the  pulmonary  vessels. 

I  have  never  met  any  thing  of  the  kind,  although  I  have  seen  aii 
enter  the  internal  jugular  vein,  and  frothy  blood  then  escape  ;  this 
had  no  perceptible  eilect  on  the  state  of  the  patient.  Different  ani- 
mals appear  to  be  susceptible,  to  various  extents,  to  the  entrance  of 
air  into  the  vessels  ;  if  we  throw  only  a  little  air  into  the  jugular  vein 
of  a  rabbit  it  dies ;  while  we  may  sometimes  throw  several  syringe- 
fuls  into  dogs  without  observing  any  effects. 

Besides  the  above  varieties  of  hasniorrhage,  we  distinguish  the  so- 
called  parenchymatous  hcBmorrhage,  which  is  sometimes  incorrectly 
identified  with  capillary  heemorrhage.  In  the  normal  tissue  of  an 
otherwise  healthy  body,  parenchymatous  haemorrhages  do  not  come 
from  the  capillaries,  but  from  a  large  number  of  sinall  arteries  and 
veins,  which  from  some  cause  do  not  retract  into  the  tissue  and  con- 
tract, and  are  not  compressed  by  the  tissue  itself.  Bleeding  from  the 
corpus  cavernosum  penis  is  an  example  of  such  parenchymatous  haem- 
orrhages, which  also  occur  from  the  female  genitals  and  in  the  peri- 
neal and  anal  regions,  as  well  as  from  the  tongue  and  spongy  bones. 
These  parenchymatous  heemorrhages  are  especially  frequent  from 
diseased  tissue ;  they  also  occur  after  injuries  and  operations,  as  so- 
called  secondary  hmrtiorrhages ;  but  we  shall  speak  of  these  here- 
after. 

One  other  point  we  must  refer  to  here  :  this  is,  that  there  are  per- 
sons who  bleed  so  freely  from  a  small,  insignificant  wound,  that  they 
may  die  of  heemorrhage  from  a  scratch  of  the  skin,  or  after  extraction 
of  a  tooth.  This  constitutional  disease  is  called  a  hcemorrhagic  dia- 
thesis y  people  affected  with  it  are  called  haemophilen.  The  cause  of 
this  disease  is  probably  abnormal  thinness  of  the  arterial  walls  ;  tliis  is 
congenital  in  most  cases,  but  may  probably  result  gradually  from  morbid 
degeneration  and  atrophy  of  the  vascular  tunics.  This  frightful  malady 
is  usually  hereditary  in  certain  families,  especially  among  the  males,  the 
females  being  less  liable  to  it.  In  these  persons  heemorrhage  is  caused 
not  only  by  wounds,  but  light  pressure  may  induce  subcutaneous  bleed- 
ing, spontaneous  haemorrhages,  as  from  the  gastric  or  vesical  mucous 
membrane,  which  may  even  prove  fatal.  It  is  not  exactly  in  laige 
wounds  where  medical  aid  is  called  at  once  or  very  soon,  but  more 
particularly  in  slight  Avounds,  that  continued  haemorrhages  occur  in 
such  persons  which  are  difficult  to  arrest,  partly,  as  we  above  stated,  on 
account  of  slight  contractility  or  total  lack  of  muscular  tissue  in  the 
vessels,  partly  on  deficient  power  of  coagulation  in  the  blood.     It  is 


SYMPTOMS— HAEMORRHAGE.  25 

trvie,  the  latter  point  has  not  been  proved  from  the  blood  that  escaped, 
for  in  the  cases  where  attention  was  directed  to  this  point  the  blood 
flowed  like  that  of  a  healthy  person. 

I  shall  also  call  your  attention  to  some  peculiarities  in  haemorrhages 
from  certain  localities,  especially  from  those  in  the  pharynx^  posterior 
nares,  and  rectum^  although,  strictly  speaking,  this  comes  in  the  domain 
of  special  surgery.  Wounds  of  the  pharnyx  or  posterior  nares,  made 
through  the  open  mouth  by  accident,  are  rare,  but,  as  a  result  of  con- 
stitutional disease,  we  may  have  very  severe  spontaneous  haemorrhage 
from  these  parts,  or  these  may  result  from  operations,  for  we  not  un- 
frequently  have  to  use  knives  and  scissors  here,  or  to  tear  out  tumors 
with  forceps.  The  blood  does  not  always  escape  from  the  mouth  and 
nose,  but  it  may  run  down  the  phar^mx  into  the  oesophagus  without 
being  perceived.  The  general  effects  of  rapid  loss  of  blood  come  on 
rapidly,  which  we  shall  soon  describe  more  minutely,  but  we  ars 
unable  to  discover  the  source  of  the  bleeding,  which  may  be  behind 
the  soft  palate.  The  patient  soon  vomits,  and  at  once  throws  up  large 
quantities  of  blood;  when  this  ceases  thei'e  is  another  pause,  and  the 
patient,  perhaps  also  the  surgeon,  thinks  the  haemorrhage  has  ceased, 
till  more  blood  is  vomited,  and  the  patient  grows  still  Aveaker.  If  the 
surgeon  does  not  recognize  these  symptoms  and  apply  proper  remedies, 
the  patient  may  bleed  to  death.  I  remember  one  case  where  several 
physicians  gave  various  remedies  for  vomiting  of  blood  and  gastric 
hsemorrhage  after  a  little  operation  in  the  throat,  and  the  source  of 
the  bleeding  was  finally  recognized  by  an  experienced  old  surgeon, 
who  arrested  it  by  local  applications,  and  thus  saved  the  hfe  of  the 
patient. 

The  same  thing  may  happen  in  liiBmon-hage  from  the  rectum. 
From  an  internal  wound  the  blood  flows  into  the  rectum,  which  is  ca- 
pable of  enormous  distention  ;  the  patient  has  a  sudden  desire  to  stool, 
and  evacuates  large  quantities  of  blood.  This  may  be  repeated  sev- 
eral times,  till  the  rectum,  irritated  by  the  expansion,  either  contracts 
and  thus  arrests  the  haemorrhage,  or  till  it  is  finallj'-  checked  artificially. 

A  rapid  excessive  loss  of  blood  induces  changes  in  the  whole  body, 
which  are  soon  perceptible.  The  face,  especially  the  lips,  becomes  pale, 
the  latter  bluish,  the  pulse  is  smaller,  and  at  first  less  frequent.  The 
bodily  temperature  sinks  most  perceptibly  in  the  extremities ;  the  pa- 
tient, especially  when  sitting  up,  is  subject  to  fainting-spells,  dizziness, 
nausea,  or  even  vomiting,  his  eyes  are  dazzled,  and  he  has  noises  in  the 
ears,  every  thing  appears  to  whirl  around ;  he  collects  his  strength  to 
hold  himself  up,  he  becomes  unconscious,  and  finally  falls  over.  These 
symptoms  of  syncope  we  refer  to  rapid  anaemia  of  the  brain.  In  a 
hoiizontal  posture  this  soon  passes  off.     Persons  often  fall  into  this 


26  SIMPLE   INCISED  WOUNDS   OF   THE   SOET   PARTS. 

state  from  very  slight  loss  of  blood,  occasionally  more  from  loathing 
and  aversion  to  the  flowing  blood  than  from  weakness.  A  single 
fainting  of  this  kind  is  no  measure  of  the  amount  of  blood  lost ;  the 
patient  soon  recovers  his  forces. 

Should  the  haemorrhage  continue,  the  following  symptoms  appear 
sooner  or  later:  the  countenance  grows  paler  and  waxy,  the  lips 
pale  blue,  the  eyes  dull,  the  bodily  temperature  is  lower,  the  pulse 
small,  thready,  and  very  frequent,  respiration  incomplete,  the  patient 
faints  frequently,  constantly  grows  more  feeble  and  anxious  ;  at  last  he 
remains  unconscious,  and  there  is  twitching  of  the  arms  and  legs,  which 
is  renewed  by  the  slightest  irritation,  as  by  the  point  of  a  needle,  etc. ; 
this  state  may  pass  into  death.  Great  dyspnoea,  lack  of  oxygen,  is  one 
of  the  worst  signs,  but  even  here  we  should  not  hesitate ;  we  can  often 
do  something  even  after  apparent  death.  Young  women  especially 
can  bear  enormous  loss  of  blood  without  immediate  danger  to  life ;  you 
will  hereafter  have  occasion  to  witness  this  in  the  obstetrical  clinic. 
Children  and  old  persons  can  least  bear  loss  of  blood  ;  in  young  children 
the  results  of  the  application  of  a  leech  are  often  evident  for  years  by 
a  very  pallid  look  and  increased  excitability.  In  very  old  persons  great 
loss  of  blood,  if  not  immediately  fatal,  may  induce  obstinate  collapse, 
wliich  after  days  or  weeks  passes  on  to  death  ;  this  is  probably  because 
the  loss  of  blood  is  immediately  supplied  by  serum,  and  in  old  persons 
the  formation  of  blood-corpuscles  goes  on  slowly ;  the  greatly-diluted 
blood  proves  insuflBcient  to  nourish  the  tissues,  whose  nutrition  is  at 
any  rate  very  sluggish. 

When  the  patient  comes  to  himself  after  severe  hasmorrhage,  he 
has  excessive  thirst,  as  if  the  body  were  dried  up,  the  vessels  of  the 
intestinal  canal  greedily  take  up  the  quantities  of  water  drunk ;  in 
strong,  healthy  persons,  the  cellular  constituents  of  the  blood  are 
quickly  replaced,  it  is  true  we  do  not  exactly  know  from  what  source ; 
after  a  few  days,  in  a  person  otherwise  healthy,  we  can  perceive  few 
signs  of  the  previous  anaemia ;  soon,  too,  his  strength  has  recovered 
from  the  exhaustion. 


LECTURE   III. 

Treatment  of  Haemorrhage.— 1.  Ligature  and  Mediate  Ligatm-e  of  Arteries.— Torsion.— 
2.  Compression  by  the  Finger;  Choice  of  the  Point  for  Compression  of  the  Larger 
Arteries.  —  Tonrniquet.  —  Acupressure.  —  Bandaging.—  Tampon.  —  3.  Styptics. — 
General  Treatment  of  Sudden  Anaemia. — Transfusion. 

Gentlemen  :  You  now  know  the  different  varieties  of  haemorrhage. 
Now,  what  means  have  we  for  arresting  a  more  or  less  severe  bleeding  ? 


TREATMENT   OF   HEMORRHAGE— IJGATURE.  27 

The  numbei-  is  great,  altliough  we  use  but  few  of  them — only  tliose 
that  are  the  most  certain.  Here  you  have  a  field  of  surgical  operation 
where  quick  and  certain  aid  is  reqviired,  so  that  the  result  must  be 
unfailing.  Still,  the  employment  of  these  remedies  requires  practice ; 
cool-blooded  quiet,  absolute  certainty,  and  presence  of  mind,  are  the 
first  requisites  in  dangerous  haemorrhage.  In  such  circumstances  a 
surgeon  may  show  of  what  metal  he  is  made. 

Haemostatics  are  divided  into  three  chief  classes :  1.  Closure  of 
the  vessel  by  tying  it — ligation.  2.  Compression.  3.  The  remedies 
that  cause  rapid  coagulation  of  blood,  st^^tics  (from  arv<poi,  to  contract). 

1.  The  ligature  may  be  applied  in  three  ways,  viz.,  as  ligature  of 
the  isolated  bleeding  vessels,  as  mediate  ligature  of  the  latter  with 
the  surrounding  soft  parts,  or  as  ligation  in  the  continuity,  i.  e.,  liga- 
tion of  the  vessel  at  some  distance  from  the  wound. 

These  varieties  of  ligation  apply  almost  exclusively  to  arrest  of 
arterial  haemorrhage.  Venous  hemorrhages  rarely  require  ligation — it 
is  only  occasionally  indicated  in  the  large  venous  trunks ;  we  avoid  it 
whenever  we  can,  as  its  results  may  be  dangerous.  We  shall  here- 
after inquire  in  what  tliis  danger  consists,  and  at  present  speak  only 
of  the  ligation  of  arteries. 

Let  us  suppose  the  simplest  case ;  a  small  artery  spurts  from  a 
wound :  you  first  seize  the  artery,  as  much  isolated  as  possible,  best 
transversely,  between  the  branches  of  a  sliding  forceps ;  then  fasten 
the  slide,  and  the  bleeding  is  stopped.  The  sliding  forceps  are  best 
made  of  German  silver,  as  it  rusts  less  readily  than  iron.  There  are 
many  difi^erent  varieties  of  these  forceps,  which  are  all  so  arranged  that 
when  closed  they  remain  fixed  in  that  position ;  the  mechanism  accom- 
plishing this  closure  varies  greatly ;  the  more  simple  it  is,  the  better. 
It  is  interesting  to  follow  the  phases  of  development  of  this  instru- 
ment since  the  days  of  Ambrose  Pare^  before  it  attained  its  present 
simple  completeness.  Of  late  small  spring  clamps  are  not  unfre- 
quently  employed  to  compress  the  bleeding  arteries ;  these  are  very 
serviceable,  if  strongly  made.  Besides  these  pincettes,  we  may  also 
use  small  curved  sharp  hooks  [BromfiekVs  artery-hook)  to  draw  out 
the  artery,  but  this  is  not  so  good  a  way,  for  of  course  the  blood 
would  continue  to  spurt  during  the  subsequent  ligation. 

Having  seized  the  artery  securely,  the  next  thing  is  to  close  it 
permanently ;  this  is  done  by  the  ligature.  But  satisfy  yourself  first 
that  you  have  not  included  a  nerve  with  it,  for  the  coincident  ligation 
of  a  nerve  may  not  only  induce  continued  severe  pain,  but  even  dan- 
gerous general  nervous  affections.  For  ligating  arteries  we  use  silk 
thread  of  various  thickness,  according  to  the  size  of  the  artery  ;  it  must 
be  good,  strong  silk,  so  that  it  shall  not  break  when  firmly  tied ;  and  it 


28  SIMPLE  IInCISED   WOUNDS   OF  THE   SOFT   PARTS. 

should  not  readily  absorb  fluids.  Have  the  forceps,  which  hang  from 
the  end  of  the  artery,  held  up,  then  from  below  place  the  silk  around 
the  arter}',  making  first  a  simple  knot  and  tying  it  tightly  just  in  front 
of  the  forceps,  then  tie  a  second  knot.  Now  loosen  the  forceps  ;  if  the 
ligature  is  rightly  applied,  the  bleeding  must  be  arrested.  The  tight- 
ening of  the  knot  must  be  accomplished  by  pushing  the  silk  forward  and 
stretching  it  with  the  points  of  both  fingers.  If  the  silk  be  good,  two 
simple  knots,  one  over  the  other,  will  suffice.  When  the  ligature  is 
firmly  applied,  cut  one  end  off  short  and  lead  the  other  out  of  the 
wound  the  shortest  way.  In  from  6  to  10  days  these  can  usually  be 
removed.  When  you  propose  to  close  the  wound  entirely,  it  is  best 
to  use  catgut  made  pliable  by  soaking  in  oil  ;  the  knots  and  loops 
are  gradually  absorbed,  and  only  rarely  thrown  ofi"  by  suppuration. 

It  is  not  always  possible  to  take  up  the  spurting  artery  and  ligate 
it  by  itself;  occasionally  it  contracts  so  strongly  into  the  tissue,  es- 
pecially into  the  muscles  or  dense  cellular  tissue,  that  its  isolation  is 
impracticable.  Under  such  circumstances  it  is  difficult  to  complete  the 
ligation  securely ;  we  are  very  apt  to  include  the  blades  of  the  forceps 
in  the  ligature,  as  it  is  difficult  to  push  the  ligature  far  enough  for- 
ward. Such  cases  are  proper  ones  for  mediate  ligation.  After  hav- 
ing pulled  forward  the  bleeding  part  with  forceps  or  a  hook,  pass  a 
curved  needle,  held  in  a  needle-holder,  around  the  arterj^,  then  tie  the 
ligature  so  as  to  encircle  the  entire  end  of  the  artery ;  tie  the  knots 
tightly,  as  above  directed  ;  thus,  while  closing  the  mouth  of  the  artery, 
you  will  enclose  some  of  the  surrounding  tissue.  Mediate  ligation  is 
only  to  be  regarded  as  an  exceptional  proceeding,  for  the  ligated  tissue 
dies  or  the  ligature  suppurates  through  very  slowly,  so  that  the  sepa- 
ration of  the  latter  is  much  impeded ;  of  course  we  must  guard  against 
including  any  visible  nerve- trunk  near  the  artery  in  the  ligature.  In  the 
percutaneous  mediate  ligation  of  Middeldorpf^  we  proceed  even  more 
summarily ;  Ave  pass  a  strongly-curved  large  needle  through  the  skin, 
under  and  across  the  bleeding  artery,  and  again  out  through  the  skin ; 
the  thread  is  tied,  and,  besides  compressing  other  parts,  compresses  the 
artery ;  the  thread  remains  two  or  three  daj^s.  I  do  not  recommend  this 
method ;  it  should  only  be  employed  in  cases  of  necessity,  and  as  a 
provisional  hasmostatic. 

Whenever  the  bleeding  artery  can  be  seen  in  the  wound,  the  haem- 
orrhage is  to  be  arrested  by  hgature ;  but,  in  those  cases  where  the 
arteries  of  the  periosteum  or  bone  spurt  out  blood,  ligature  is  impos- 
sible, and  other  methods,  such  as  compression,  come  into  play. 

If  you  have  to  deal  with  large  bleeding  arteries,  the  proceeding  is 
just  the  same,  only  you  must  be  doubly  careful  in  isolating  the 
artery :    seize  the  bleeding  end  and   scrape   back   the    surrounding 


TREATMENT   OF   HEMORRHAGE— COMPRESSION.  29 

tissue  with  a  small  scalpel,  then  lig-ate  carefully  and  accurately ;  in 
most  cases,  when  you  have  the  central  and  peripheral  ends  exposed  in 
the  wound,  you  shovild  ligate  both,  for  the  anastomoses  in  the  arterial 
system  are  so  free  that,  if  the  peripheral  end  does  not  bleed  at  once, 
it  may  do  so  later. 

The  wound  from  which  a  copious  haemorrhage  comes  may  be  very 
small,  as  a  punctured  or  gun-shot  wound.  From  your  anatomical 
knowledge  you  should  know  what  large  vessel  may  be  injured  by  such 
a  wound.  If,  from  the  free  haemorrhage  or  its  frequent  recurrence 
after  compression,  j-ou  are  satisfied  that  ligation  is  the  only  certain 
remedy  for  the  bleeding,  you  have  the  following  alternatives :  either 
enlarge  the  existing  wound  by  careful,  clean  incisions,  and  seek  for 
the  vessel  in  the  wound  while  the  artery  is  compressed  above,  and 
Ligate  the  divided  ends  of  the  artery ;  or  else,  while  you  have  the 
bleeding  vessel  compressed  in  the  wound,  you  seek  the  central  part  of 
the  vessel  above  the  wound,  and  then  ligate  in  the  continuity.  Both  o|> 
erations  demand  accurate  anatomical  knoM'ledge  of  the  positions  of  the 
arteries,  and  practice.  Which  of  these  two  operations  you  shall  choose 
depends  on  how  you  can  soonest  prudently  attain  your  object,  and 
on  which  of  them  will  require  the  smaller  new  wound.  If  you  tliink 
you  can  expose  the  artery  in  the  wound  without  enlarging  it  much, 
choose  this  method  as  the  more  certain ;  but  if  you  consider  this  very 
difficult,  if  at  the  seat  of  the  wound  the  artery  lies  deep  under  muscles 
and  fascia,  especiall}'  in  very  muscular  or  fat  persons,  make  a  regular 
ligation  of  the  ai-tery  above  (toward  the  heart  from)  the  wound. 

I  shall  not  here  discuss  the  points  chosen  after  years  of  trial,  on 
theoretical  and  practical  grounds,  for  the  ligation  of  arteries.  In  op- 
erative surgery,  in  the  text-books  on  surgical  anatomy,  and  especially 
in  the  operative  course,  you  will  be  instructed  on  this  point,  and  must 
attain  practice  in  certainly  finding,  neatly  exposing,  and  carefully 
Ligating,  the  artery,  in  doing  which,  you  cannot  accustom  yourself  to 
too  much  pedantry  and  technicality. 

Although  the  value  of  the  ligature  is  recognized  by  all  surgeons 
of  the  present  day,  still  attempts  have  been  constantly  made  to  find 
simpler  substitutes  which  should  be  just  as  safe.  Some  have  con- 
sidered it  (unjustly,  as  it  seems  to  me)  a  great  evil  to  leave  in  the 
wound  a  silk  tliread  and  a  portion  of  ligated  vessel  to  die  and  be- 
come putrid.  I  pass  over  the  attempts  and  proposals  made  for  allow- 
ing the  ligature  to  heal  in  the  cicatrix,  and  merely  mention  torsion 
of  the  bleeding  artery  as  a  mode  of  closing  the  vessel  mechanically 
till  its  walls  grow  together.  The  bleeding  vessel  is  seized  with 
strong,  accurately-closing  forceps,  drawn  forward  half  an  inch,  and 
twisted  on  its  axis  five  or  six  times  ;  I  usually  draw  it  out  as  far  as 


30  SIMPLE  INCISED   WOUNDS   OF  THE   SOFT   FARTS. 

possible,  and  twist  till  it  breaks  off.  In  this  way  I  have  twisted  ves- 
sels from  tlie  smallest  size  to  that  of  the  brachial,  so  as  to  securely 
arrest  the  bleeding.  If  branches  leave  the  artery  just  above  tbe 
bleeding-point,  it  will  not  be  movable  enough  to  make  the  torsion 
securely ;  hence  I  have  never  tried  torsion  for  the  femoral ;  but  other 
surgeons  have  done  so  successfully. 

2.  Compression. — Pressure  on  the  bleeding  vessel  with  the  finger 
is  such  a  simple,  apparent  method  of  arresting  haemorrhage,  if  we 
may  call  it  a  method,  that  it  is  strange  the  laity  do  not  resort  to  it  at 
once ;  any  person  that  has  seen  one  or  two  operations  would  instinc- 
tively hold  his  finger  on  the  bleeding  vessel ;  still  how  rarely  peojDle 
do  this  in  a  case  of  accidental  wound !  They  prefer  resorting  to  all 
sorts  of  home  remedies ;  spider-webs,  hair,  urine,  and  all  sorts  of  filth, 
are  smeared  over  the  wound,  or  else  they  run  for  some  old  woman 
who  can  arrest  the  bleeding  by  magic.  And  no  one  around  thinks  of 
compressing  the  woimd. 

Methodical  compression  may  be  made  for  one  of  two  purposes,  as 
provisional  or  permanent. 

Provisional  compression,  which  is  used  till  we  can  determine 
how  the  bleeding  may  be  best  arrested  permanently,  may  either  be 
made  by  pressing  the  bleeding  vessel  in  the  wound  against  a  bone,  if 
possible,  or  by  pressing  the  central  part  of  the  artery  against  the 
bone  at  some  distance  from  the  wound ;  the  former,  as  we  have  al- 
ready stated,  is  to  be  done  when  we  propose  to  ligate  the  trunk  ;  the 
latter,  when  we  wish  to  tie  the  bleeding  end  of  the  artery,  or  to  ex- 
amine the  wound  more  carefully. 

Where  shall  we  compress  the  arter}-,  and  how  shall  we  do  it  most 
effectually?  To  compress  the  right  carotid,  you  would  place  your- 
self behind  the  patient,  and  lay  the  tips  of  the  second,  third,  and 
fourth  fingers  of  the  right  hand  along  the  anterior  border  of  the 
stemo-cleido-mastoideus  muscle,  about  the  middle  of  the  neck,  and 
press  firmly  against  the  spine,  while  you  pass  the  thumb  around  the 
neck,  and  with  the  left  hand  bend  the  patient's  head  gently  to  the 
wounded  side  and  somewhat  backward.  You  should  distinctly  feel 
the  pulsation  of  the  carotid  artery.  Firm  pressure  here  is  quite  pain- 
ful for  the  patient,  for  the  vagus  nerve  is  unavoidably  compressed,  and 
the  tension  of  the  parts  necessarily  acts  on  the  larynx  and  trachea. 
From  the  free  anastomoses  of  the  two  carotids,  the  effect  of  compres- 
sion of  one  of  them,  in  arresting  bleeding  from  an  artery  of  the  head 
or  face,  is  not  generally  very  great,  and  perfect  compression  of  both 
vessels  requires  so  much  space,  that  we  must  generally  be  satisfied 
with  diminishing  the  volume  of  the  arteries  by  incomplete  compret*- 
Bion.     Compression  of  both  carotids  is  always  a  very  painful  and  ter- 


TREATMENT   OF  HEMORRHAGE— COMPRESSION.  31 

rifying  operation  for  the  patient,  especially  on  account  of  the  strong 
secondary  pressure  made  on  the  larjmx  and  trachea ;  hence  it  is  rarely 
employed. 

Compression  of  the  subclavian  artery  may  be  more  frequently  re- 
quired, especially  in  wounds  of  this  artery  in  MohrenheimH s  fossa  and 
in  the  axilla.  In  this  operation  also  you  may  best  stand  behind  the 
recumbent  or  half-sitting  patient ;  with  yotir  left  hand  incline  the  head 
of  the  patient  toward  the  wounded  (right)  side,  and  push  your  right 
thumb  firmly  behind  the  outer  border  of  the  clavicular  portion  of  the 
relaxed  sterno-cleido-mastoid  muscle,  so  that  you  may  firmly  compress 
the  artery  against  the  first  rib,  at  the  point  where  it  passes  forward 
between  the  scaleni  muscles.  Here  also  pressure  is  painful,  from  the 
Uability  of  the  brachial  plexus  of  nerves  to  be  included  in  the  com- 
pression ;  still,  by  employing  sufficient  force,  we  may  completely  com- 
press the  artery  so  as  to  arrest  pulsation  of  the  radial.  But  the  thumb 
soon  gi'ows  tired  and  loses  sensation ;  hence  various  aids  have  been  de- 
vised— instruments  by  which  the  compression  may  be  made  certainly. 
One  of  the  most  convenient  means  is  a  short  thick  key  whose  wards 
are  wrapped  in  a  handkerchief  and  the  handle  held  firmly  in  the  palm 
of  the  hand ;  you  place  the  wards  of  the  key  over  the  artery,  and 
compress  it  firmly  against  the  first  rib.  But  this  cannnot  fully  replace 
compression  by  the  finger  of  a  skilled  assistant,  for  with  the  instrument 
you  of  course  cannot  feel  if  the  artery  slides  away  from  the  pressure. 

From  its  position  the  brachial  artery  may  of  course  be  readily 
compressed  ;  in  doing  this,  you  place  yourself  on  the  outer  side  of  the 
arm,  take  the  arm  in  your  right  hand,  so  as  to  lay  the  second,  third, 
and  fourth  fingers  along  the  inner  side  of  the  belly  of  the  biceps,  about 
the  middle  of  the  arm  or  a  little  above  it,  surround  the  rest  of  the 
arm  with  the  thumb,  and  press  against  the  humerus  with  the  fingers ; 
the  only  difficulty  here  is.  to  avoid  simultaneous  compression  of  the 
median  nerve,  which  at  this  point  almost  covers  the  artery.  By  com 
pressing  the  brachial  artery,  we  may  readily  arrest  the  radial  pulse, 
and  we  may  employ  this  compression  with  great  advantage  if  we  de- 
sire to  ligate  either  the  radial  or  ulnar  artery  on  account  of  wounds, 
or  to  amputate  at  the  forearm  or  the  lower  part  of  the  arm. 

In  hasmorrhages  from  the  arteries  of  the  lower  extremities  we  com- 
press the  femoral  artery  at  its  commencement,  that  is,  immediately 
below  Poupar€s  ligament.  Here,  where  it  lies  just  in  the  middle  be- 
tween the  tuberculum  pubis  and  anterior  inferior  crest  of  the  ileum, 
the  artery  should  be  pressed  against  the  horizontal  branch  of  the  pubis. 
Tlie  patient  should  be  recumbent ;  compression  should  be  made  with 
the  thumb,  and  is  easy,  because  at  this  point  the  artery  is  superficial. 
As  far  down  as  the  lower  third  of  the  thigh,  the  femoral  artery  may 


32  SIMPLE   INCISED  WOUNDS   OF   THE  SOFT  FARTS. 

be  compressed  against  tlie  femur,  but  this  can  only  be  done  certainly 
by  the  finger  in  very  thin  persons ;  in  most  cases  we  employ  for  this 
purpose  a  special  compress  called  a  tourniquet. 

By  a  tourniquet  we  mean  an  apparatus  by  which  we  press  an 
elongated  oval  piece  of  wood  or  leather,  a  pad,  against  an  artery,  and 
this  against  the  bone,  by  means  of  a  twisting,  screwing,  or  budding 
mechanism.  Since  a  long  comiDression  of  the  brachial  or  femoral  ar- 
teries is  very  fatiguing,  we  may  advantageously  call  it  to  aid  in  com- 
pressing these  artex'ies.  The  form  of  instrument  that  we  now  employ 
is  the  screw  tourniquet  of  JTean  Louis  Petit.  The  pad,  which  is  mov- 
able on  a  band,  is  to  be  applied  exactly  over  the  point  corresponding 
to  the  artery,  and  opposite  the  screw,  under  which  a  few  folds  of  linen 
are  to  be  placed,  to  prevent  too  great  pressure  on  the  skin.  Then 
buckle  the  band  around  the  extremity,  and  by  means  of  the  screw  and 
band  draw  the  pad  tighter  till  the  subjacent  artery  ceases  to  pulsate. 
In  an  amputation-wound,  if  we  do  not  at  once  see  the  mouth  of  the 
artery,  we  may  loosen  the  screw  slightly  and  permit  a  little  blood  to 
escape  from  the  artery,  which  at  once  shows  its  position ;  then  screw 
up  the  tourniquet  at  once,  and  ligate  the  artery.  This  is  the  great  ad- 
vantage of  the  screw.  "N^Tien  the  apparatus  is  well  made  and  careful- 
ly ajjplied,  it  is  of  excellent  service.  It  is  true,  the  band  around  the 
limb  unavoidably  compresses  the  veins,  especially  the  subcutaneous 
veins;  nevertheless,  on  account  of  the  pad,  it  acts  chiefly  on  the  artery. 
With  a  piece  of  broad  bandage  and  a  round  block  of  wood,  or  a  roller 
of  bandage  and  a  short  stick,  you  may  readily  improvise  such  a  tour- 
niquet; still,  if  this  improvised  apparatus  does  not  secure  the  artery 
very  firmly  and  securely,  I  should  advise  more  certain  modes  of  com- 
pression, of  which  I  shall  speak  immediately.  The  facility  of  check- 
ing even  considerable  hcemorrhages  by  means  of  the  tourniquet,  might 
delude  us  into  leaving  it  on  for  a  long  while,  until  the  bleedhig 
stopped  of  itself,  and  we  should  thus  escape  the  trouble  of  ligating. 
This  would  be  a  great  error.  If  the  tourniquet  remains  on  half  an 
hour,  the  extremity  below  it  groAvs  blue,  swells,  loses  sensation,  and 
circulation  in  the  part  may  be  entirely  arrested,  and  it  will  die ; 
through  yoiu-  whole  life  you  would  blame  yourself  for  such  an  error, 
which  might  greatly  endanger  the  life  of  your  patient. 

Hence,  application  of  the  tom-niquet  is  only  admissible  as  a  prf)- 
visional  hsemostatic.  It  is  almost  impracticable  to  compress  a  large 
artery  with  the  finger  till  the  hemorrhage  shall  be  certainly  arrested 
spontaneously.  Still,  cases  may  arise  where  compression  with  the 
finger  is  the  only  certain  mode  of  arresting  bleeding  from  smaller  ar- 
teries, as  in  haemorrhages  from  the  rectum  or  deep  in  the  pharynx, 
when  other  means  have  failed;   here,  compression  with  the  fingei 


TREATMENT  OF  HJEMORRHAGE— COMPRESSIOX.  33 

must  sometimes  be  continued  half  an  hour  to  an  hour,  or  longer,  for 
ligation  of  the  internal  iliac  in  the  former  case,  and  of  the  carotid 
in  the  latter,  are  as  dangerous  as  they  are  uncertain  for  a  permanent 
arrest  of  the  bleeding. 

To  avoid  the  danger  from  venous  congestion  after  constricting 
the  limb,  before  applying  the  tourniquet  we  may  apply  a  bandage 
firmly  to  the  extremity  from  below  upward,  and  thus  press  the 
blood  out  from  the  limb.  Formerly  this  procedure  was  applied  to 
limbs  about  to  be  amputated,  and  thus  the  haemorrhage  was  reduced 
to  a  minimum.  Granclesso  Silvestri,  a  physician  of  Vicenza,  rec- 
ommended elastic  bandages  for  this  purjDOse,  and  instead  of  the  tour- 
niquet applied  a  thick  elastic  tube  several  times  around  the  limb. 
In  ignorance  of  this  advice,  which  was  little  known,  Esmarch  re- 
sorted to  the  same  method,  and  called  attention  to  the  great  bene- 
fits derived  from  it ;  since  when  it  has  become  very  popular.  In 
fact,  by  means  of  this  appliance  long  operations  may  be  done 
without  loss  of  blood.  The  extremities  may  be  rendei'ed  bloodless 
and  kept  so  for  an  hour  without  injuring  their  vitality.  After  ligat- 
ing  all  the  visible  vessels,  the  elastic  tube  is  to  be  loosened,  and 
the  blood  will  again  enter  the  vessels  ;  if  any  more  then  permit  the 
escape  of  blood,  they  may  be  ligated.  This  method  of  making  a 
limb  bloodless  and  keeping  it  so  is  a  great  advance  in  modern  sur- 
gery ;  and  by  this  means  operations  may  be  done  which  without  it 
we  should  not  have  dared  to  attempt. 

[The  bleeding  which  follows  removal  of  the  elastic  tube  is  the 
only  objection  to  its  use.  Attemjjts  have  been  made  to  prevent  it 
by  applying  a  strong  current  of  electricity  to  the  wound  before  re- 
moving the  tube,  but  this  is  not  reliable.  It  is  better,  instead  of 
applying  a  bandage,  to  hold  the  limb  vertical  for  a  time,  then  put 
on  the  tube.  The  limb  is  not  rendered  so  bloodless  by  this  means, 
but  after  the  tube  has  been  removed  there  is  less  bleeding. 

Forced  compression  by  means  of  spring  forceps  has  been  used 
by  Koeherle  and  Vemeuil,  especially  where  the  artery  was  not  very 
accessible.  The  bleeding  vessel  may  be  isolated  or  seized  with  sur- 
rounding tissues,  the  forceps  being  left  in  place  a  few  minutes  for 
small  vessels,  and  for  larger  ones  as  much  as  twenty-four  hours, 
when  the  calibre  will  be  occluded  by  coagulum.  This  procedure  is 
good  in  some  cases,  but  cannot  replace  the  ligature.  Vanzetti's  un- 
cipressure  depends  on  the  same  principle  :  where  there  is  bleeding 
from  a  deep  wound,  traction  with  a  hook  in  a  certain  direction  com- 
presses the  vessel  by  the  tension  and  arrests  the  hosmorrhage. 

A  very  important  method  of  arresting  haemorrhage  is  compres- 
sion of  the  bleeding  vessels  by  pressure  on  the  skin  or  the  wounded 
4 


34  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

surface  ;  when  circumstances  are  favorable,  that  is,  when  the  bleed- 
ing vessel  can  be  pressed  against  some  firm  body,  as  a  bone,  bleed- 
ing may  always  be  arrested  in  this  way.  On  the  same  principle  we 
may  try  forced  flexion  of  limbs  to  an  acute  angle  ;  of  course,  this  is 
only  applicable  to  the  extremities.  If  we  flex  the  elbow  or  knee  to 
the  maximum,  the  pulse  disappears  below  the  joint  from  comj^res- 
sion  of  the  artery.  This  operation  has  been  used  for  ha?morrhage 
as  well  as  for  aneurisms,  but  from  the  simultaneous  compression  of 
the  nerves  it  is  very  jjainful,  and  cannot  be  very  long  continued. 

Cold  has  long  been  used  as  a  haemostatic,  and  now  heat  is  applied 
for  the  same  purpose  ;  this  seems  paradoxical,  as  warmth  generally 
induces  expansion  and  relaxation.  This  is  true  of  moderate  degrees 
of  heat,  while  higher  ones  are  irritating  and  cause  contraction  of 
the  tissues  and  vessels.  In  hsemorrhages  from  the  uterus  injections 
of  hot  water  are  very  serviceable,  apparently  from  inducing  active 
contractions  of  the  organic  muscular  fibres  of  the  uterus  ;  in  haem- 
orrhages from  vessels  not  lying  in  contractile  tissue,  as  after  ampu- 
tations, irrigation  with  hot  water  causes  temporary  arrest  of  bleed- 
ing, but  this  soon  recurs  with  greater  energy  than  if  the  vessels  had 
been  left  to  themselves. 

Recently  I  have  tiied  the  Penghawar  Djambi  a  few  times,  and 
can  testify  that  when  quantities  of  it  are  pressed  firmly  on  the 
wound  it  acts  better  than  charpie  as  a  styptic  ;  I  will  not  pretend 
to  say  that  it  is  better  than  liquor  ferri,  but  it  smears  the  wound 
less,  even  if  left  on  for  some  days,  Penghawar  Djambi  is  the  light 
yellowish,  soft,  hairy  substance  from  the  trunk  of  the  Cibotium 
Cuminghii,  a  native  of  the  East  Indies,  [This  must  closely  resem- 
ble the  styptic  cotton  so  commonly  used  by  us.  During  the  past 
year,  1878,  Paquelhi's  cautery  has  been  iised  a  good  deal,  and  is 
very  convenient.  By  a  hand-bellows  a  stream  of  benzine  vapor  is 
thrown  against  a  platinum  cap  which  has  been  previously  heated  in 
a  spirit-lamp  ;  after  it  has  once  reached  a  red  or  white  heat,  it  is 
easily  kept  at  that  point  by  the  benzine  vapor.  It  is  readily  used, 
and  when  at  a  white  heat  its  application  is  not  painful.  For  haem- 
orrhages from  the  vagina  or  uterus,  water  at  a  temperature  of  110° 
to  125°  Fahr,  may  be  injected  for  some  time  by  means  of  David-- 
soil's  syringe,] 

[In  a  pure  incised  or  punctured  wound  one  of  the  symptoms  is 
extravasation,  that  is,  an  escape  of  fluid  from  the  tissues ;  usually  we 
only  think  of  the  extravasation  of  blood,  as  this  is  the  most  appar- 
ent. But  there  are  non-vascular  tissues,  such  as  the  cornea,  which 
do  not  bleed  ;  and,  moreovei*,  in  every  incised  or  punctured  wound 
there  is  an  escape  of  lymph  from  the  interspaces  of  the  skin  and 


TREATMENT   OF   OiEMORRnAGE— COMPRESSION.  35 

connective  tissues,  which  is,  however,  usually  obscured  by  the 
bleeding.  Opening  of  physiological  cavernous  tissues  may  also 
allow  other  fluids  to  be  mixed  with  the  blood.  Escape  of  the  fluids 
of  the  tissues,  especially  lymph,  requires  no  particular  treatment.] 

Quite  recently  the  genial  surgeon  and  obstetrician,  Simpson^  of  Ed- 
inburgh, Avhom  you  already  know  as  the  introducer  of  chloroform, 
has  recommended  a  method  which  I  cannot  recognize  as  a  perfect  sub- 
stitute for  ligation,  but  which  is  in  man}'  cases  of  practical  use ;  this 
is  the  compression  of  the  bleeding  artery  by  a  needle — acupressure. 
Acupressure  may  be  made  in  various  ways.  For  instance,  in  an  am- 
putation-flap, you  introduce  a  long  insect,  or  sewing-needle,  nearly 
vertically  through  the  skin  and  soft  parts  to  within  one-quarter  or 
one-half  an  inch  of  the  artery ;  tui'n  the  needle  horizontally,  bring  its 
point  close  over  or  under  the  artery,  and  at  about  the  same  distance 
from  the  artery  you  push  it  into  the  soft  parts,  and  pass  it  out  through 
the  skin  nearly  vertically,  so  that  the  artery  shall  be  compressed  be- 
tween the  needle  and  the  soft  parts,  or,  still  better,  against  a  bone. 
Should  this  compression  not  act  loerfectly,  as  it  would  rarely  be  likely 
to  in  large  arteries,  if  the  first  needle  was  applied  above  the  artery, 
pass  a  second  one  below  it,  and  so  compress  the  artery  between  the 
two  needles,  or  else  press  the  artery  against  the  needle  by  means  of 
a  wire  loop.  In  amputations  I  prefer  acupressure  by  torsion ;  I  pass 
the  needle  transversely  through  the  artery,  which  is  drawn  forAvard, 
and  with  the  needle  make  a  half  or  whole  rotation  in  the  direction  of 
the  radius  of  the  surface  of  the  flap,  until  the  bleeding  is  arrested, 
and  then  insert  the  point  of  the  needle  into  the  soft  parts.  The 
needles  may  be  removed  after  forty-eight  hours,  Avithout  renewal  of 
bleeding.  The  extensive  experience  of  English  surgeons  in  the  suc- 
cess of  this  bold  operation  first  gave  me  coirrage  to  try  it,  and  I  must 
acknowledge  that  in  several  amputations,  even  of  the  thigh.  I  have 
seen  no  objection  to  it.  I  cannot  quite  believe  that  acupressure  will 
altogether  displace  ligation,  as  Simpson  prophesied.  In  this  opera- 
tion, to  which  I  have  resorted  in  most  of  my  amputations  for  several 
years,  I  employ  long  golden  needles  with  large  heads,  because  other 
metalS  rust  easily,  and  silver  is  too  soft,  and  platinum  too  expensive. 

Quite  recently  Von  JBruns  has  applied  small  ligature  rods,  with 
which  loops  of  silk  are  applied  around  and  retained  against  the 
artery,  previously  drawn  out.  These,  like  acupressure-needles,  are  re- 
moved after  forty-eight  hours.  I  have  just  tried  this  procedure  with 
perfect  success  on  the  femoral  artery  in  an  amputation  of  the  thigh. 

In  venous  haemorrhage,  or  bleeding  from  numerous  ^mall  arteries, 
especially  in  so-called  parenchymatous  hremorrhage,  a  regular  tampon 
must  be  applied,  by  means  of  l^andages,  compresses,  and  charpie. 


36  SIMPLE   INCISED  WOUNDS   OF   THE   SOFT   PARTS. 

If  you  have  a  liajmorrhage  from  tlie  arm  or  leg,  that  you  wish  to 
arrest  by  compression — if,  for  instance,  large  quantities  of  blood  are 
being  poured  out  from  a  dilated  diseased  vein,  or  if  there  be  bleeding 
from  numerous  small  arteries — you  may  apply  a  bandage  firmly  from 
the  lower  to  the  upper  part  of  the  extremity,  haidng  previously  covered 
the  wound  with  a  compress  and  charpie,  and  after  applying  several 
thicknesses  of  linen  along  the  course  of  the  chief  artery  of  the  extremity. 
For  the  latter  purpose  you  may  also  employ  the  graduated  compress, 
which  3^ou  will  learn  to  make  in  the  course  on  bandages.  To  this, 
which  is  called  Thedeii's  dressing,  it  is  well  to  add  a  splint,  to  keep 
the  extremity  perfectly  quiet,  for  the  bleeding  is  readily  renewed  by 
muscular  contractions.  These  graduated  compresses,  carefully  made, 
are  particulaily  serviceable  on  the  battle-field,  in  gun-shot  and  punc- 
tured wounds ;  by  their  aid  we  may  arrest  haemorrhage  from  the  radi- 
al ulnar,  anterior  and  posterior  tibial,  and  even  from  the  brachial  and 
femoral  arteries.  In  the  former  or  smaller  arteries,  by  leaving  the  dress- 
ino-  on  six  or  eight  days,  we  may  arrest  the  bleeding  permanently, 
but  in  the  latter  it  only  acts  as  a  provisional  haemostatic  ;  it  must  be 
followed  by  ligation,  if  we  wish  to  be  at  all  sure  of  avoiding  a  recur- 
rence of  the  bleeding.  We  may  also  employ  compression  in  haemor- 
rhages from  the  thorax,  as  in  case  of  parenchymatous  haemorrhage 
after  removal  of  a  diseased  breast;  here  we  may  dress  the  wound  with 
compresses  and  charpie,  and  retain  them  in  position  by  bandages 
around  the  thorax.  But,  for  such  a  bandage  to  be  efficacious,  it  must 
be  very  annoying  to  the  patient ;  on  the  whole,  it  is  better  to  ligate 
the  bleeding  arteries,  even  if  there  should  be  many  of  them ;  by  so 
doing,  both  you  and  yowt  patients  will  be  better  off",  for  you  will  not 
be  worried  and  disturbed  by  the  secondary  haemorrhages  follomng 
these  operations  as  a  result  of  hasty  ligation  and  insufficient  compres- 
sion. 

In  some  parts  of  the  body  you  cannot  emjiloy  compresses,  as  in 
bleeding  from  the  rectum,  vagina,  or  posterior  nares.  Here  the  tam- 
pon (from  tampon,  plug)  is  ser^dceable.  Tliere  are  many  varieties  of 
tampons,  especially  for  hajmorrhage  from  the  vagina  or  rectum.  One 
of  the  simplest  is  as  follows :  Take  a  four-cornered  piece  of  linen, 
about  a  foot  square ;  placing  the  middle  of  this  over  two,  three,  or  five 
fingers  of  your  right  hand,  pass  it  into  the  vagina  or  rectum,  and  fill 
the  space  left  by  the  removal  of  your  hand  with  as  much  charpie  as 
you  can  get  in,  so  that  the  vagina  or  rectum  will  be  fully  distended 
from  within,  and  thus  strong  pressure  tie  made  on  its  walls ;  when  the 
haemorrhage  is  arrested,  leave  the  ta  mpon  in  till  the  next  day,  or  longer 
if  necessary,  then  remove  it  by  gentle  traction  on  the  linen,  which 


TKEATMEXT   OF   HEMORRHAGE— STYPTICS.  37 

serves  as  a  sac  for  the  charpie.  You  may  also  make  a  ball  of  cliarpie  or 
linen  by  wrapping  a  string  around  it,  and  leave  a  long  string  hano-incr 
out  by  which  to  remove  it ;  as  such  a  tampon  may  be  either  too  large 
or  too  small,  I  prefer  the  first  method,  in  which  we  may  fill  the  linen 
sac  to  the  extent  we  desire. 

If  the  bleeding  come  from  the  portio  vaginalis  uteri,  after  an 
operation,  for  instance,  a  more  certain  way  is  to  hold  back  the  poste- 
rior wall  with  a  large  Shns^s  speculum,  thus  bringing  the  portio  vagi- 
nalis into  view,  and  press  a  tampon  firmly  against  the  bleeding  part ; 
for  it  requires  an  incredible  quantity  of  charpie  to  fill  the  vagina  of  a 
woman  who  has  borne  many  children,  so  that  no  blood  can  pass 
through,  and  it  causes  great  pain. 

In  profuse  bleeding  from  the  nose,  which  mostly  comes  from  the 
posterior  part  of  the  inferior  meatus,  and  not  unfrequently  from  the 
posteriorly-situated  cavernous  tissue  of  the  lower  turbinated  bone, 
plugging  the  nose  from  the  front  proves  inefficacious  and  useless ;  the 
bV.eding  continues,  and  the  blood  either  passes  into  the  pharj^nx  or 
flows  out  of  the  other  nostril,  as  the  patient  jiresses  the  velum  pen- 
dulum palati  against  the  wall  of  the  pharynx,  and  shuts  off  the  upper 
part  of  the  pharyngeal  cavity.  Hence,  we  must  be  prepared  to  plug 
the  posterior  nares ;  we  may  do  this  by  the  aid  of  J^elloc^s  sound.  This 
exceedingly  convenient  instrument  consists  of  a  canula  about  six  inches 
long  and  slightly  curved  at  one  end ;  in  the  canula  is  a  steel  spring  of 
much  greater  length,  with  a  perforated  button-head  at  one  end.  You 
prepare  beforehand  a  thick  plug  large  enough  to  fill  the  posterior  nares, 
and  have  a  thread  attached  to  it,  (You  may  make  this  plug  by  lav- 
ing threads  of  charpie  side  by  side  and  tying  them  tightly  together  in 
the  middle  with  a  silk  thread.)  You  apply  this  plug  by  passing  the 
instrument,  with  retracted  spring,  through  the  inferior  nasal  meatus, 
then  pushing  the  spring  forward  till  it  appears  below  the  velum  in  the 
mouth.  Pass  the  thread  attached  to  the  plug  through  the  eye  in  the 
head  of  the  spring,  tie  it  there,  and  draw  both  canula  and  spring  out 
of  the  nose  ;  the  thread  attached  to  the  latter  and  the  plug  fast  to  this 
must  follow,  and  if  you  draw  tightly  on  the  thread  the  plug  is  pressed 
firmly  into  the  posterior  nares ;  if  the  bleeding  be  now  arrested,  as  it  usu- 
ally is,  if  the  plug  (which  should  not  be  long  enough  for  its  end  to  reach 
the  larynx)  was  not  too  small,  you  cut  loose  the  thread,  leave  the  plug 
in  till  the  next  day,  then  withdraw  it  by  the  thread  left  hanging  from 
the  mouth ;  this  is  usually  easily  done,  as  the  plug  is  generally  covered 
with  mucus  and  is  consequently  smooth.  As  this  instrument  is  nor, 
always  at  hand,  we  may  use  an  elastic  catheter  or  a  thin  slip  of  whale- 
bone for  the  same  purpose,  introducing  it  through  the  nose  seizing  it 


38  SDirLE   INCISED  WOUNDS   OF   THE   SOFT   FARTS. 

with  tlie  finger  beliiad  fhe  velum,  and  bringing  the  end  out  of  the 
mouth  to  tie  the  tliread  to  it.  But  the  employment  of  this  substitute 
requires  more  dexterity  than  is  necessary  for  Belloc's  sound. 

3.  Styptics  are  remedies  which  act  partly  by  causing  contraction 
of  the  tissue,  partly  by  inducing  rapid  and  firm  coagulation.  The  num- 
ber of  remedies  recommended  is  immense  ;  "we  shall  only  mention  those 
that  have  a  proved  reputation  under  certain  circumstances. 

Cold  not  only  irritates  the  arteries  and  veins  to  contract,  but  also 
makes  the  other  soft  parts  contract  and  thus  compress  the  vessels ;  the 
current  of  blood  is  gradually  more  obstructed,  and  may  even  stagnate 
entirely,  when  the  part  is  completely  frozen.  It  seems  to  me,  however, 
that  the  recommendation  of  cold  as  a  hsemostatic  is  often  carried  too 
far ;  I  advise  you  not  to  rely  on  it  too  much.  Cold  may  be  employed 
as  follows:  first,  we  may  squirt  ice-water  against  the  bleeding  wound, 
or  into  the  vagina,  rectum,  into  the  bladder  through  a  catheter,  into 
the  nose  or  mouth — here  the  mechanical  irritation  of  a  strong  stream 
of  water  is  added  to  that  of  the  cold  ;  or  j^ou  may  lay  pieces  of  ice  on 
the  wound,  or  introduce  them  into  the  cavities,  or  have  them  swallowed 
in  gastric  or  pulmonary  hgemorrhage;  or,  lastly,  you  may  fill  a  bladder 
with  ice  and  apply  to  the  wound,  to  be  left  on  for  hours  or  days. 

The  absolute  quiet  to  be  observed  in  all  hsemorrhages  and  the  dim- 
inution in  size  of  the  arteries  as  a  result  of  the  bleeding  that  has 
already  occurred,  may  often  have  more  effect  in  arresting  the  hasmor- 
rhage  than  ice  has,  while  it  receives  all  the  credit.  I  will  not  dissuade 
vou  from  using  cold  in  moderate  parenchymatovis  haemorrhages,  but 
do  not  expect  too  m.uch  from  it  in  bleeding  from  large  arteries,  and 
do  not  waste  too  much  time  over  it,  for  time  is  blood — blood  is  life. 

The  same  is  true  of  the  common  local  remedies,  vinegar,  solution 
of  alum,  etc.,  which  also  contract  the  tisues  and  thus  compress  the 
vessels ;  they  are  very  good  for  arresting  capillary  h;^morrhages  from 
the  nose,  but  you  must  not  expect  any  thing  wonderful  from  them. 

The  hot  iron,  ferrum  candens,  causticum  actuale,  acts  by  charring 
the  ends  of  the  vessels  and  the  blood,  and  the  escape  of  the  blood  is 
arrested  by  the  resulting  firm  slough.  You  only  need  to  hold  a  rod  of 
iron  with  a  wooden  handle  at  one  end,  and  at  the  other  a  small  iron 
head  heated  to  a  white  heat,  close  to  the  bleeding  spot,  to  form  a  black 
crust  instantly  ;  indeed,  the  tissue  occasionally  blazes  up  even  from  the 
radiated  heat.  A  red-hot  iron  pressed  on  the  bleeding  spot  has  the 
same  effect,  but  is  apt  to  cling  to  the  resulting  eschar  and  pull  it  off 
again.  This  iron  rod  (cautery  iron)  is  usually  heated  to  the  proper 
degree  in  a  furnace  with  bellows.  Under  some  circumstances  the  hot 
iron  may  be  very  convenient  for  arresting  haemorrhage ;  formerlv,  be- 


TREATMENT   OF    QJEMORRHAGE.  39 

fore  ligation  was  known,  it  was  the  most  celebrated  styptic.  The 
Arabian  surgeons  usually  heated  their  amputating  knives  red  hot,  a 
proceeding  that  even  Fahricius  Hildanus  extolled,  although  he  pre- 
lerred  burning  the  bleeding  arteries  separately  wuth  fine-pointed  cau- 
teries, in  which  he  must  have  had  an  enviable  expertness. 

Quite  recently  a  similar  method  has  been  invented,  namely,  the 
use  of  platinum  heated  by  the  galvanic  battery.  This  is  the  so-called 
galvano-caustic  introduced  into  Gerinany  by  Middeldorpf^  which  may 
sometimes  be  employed  with  advantage.  As  you  may  readily  under- 
stand, in  practice  we  have  not  always  at  hand  an  iron  properly  shaped 
for  arresting  haemorrhage,  such  as  you  see  in  the  surgical  clinics. 
Dieffenbach,  the  most  talented  German  operator  of  this  century,  who 
was  at  the  same  time  a  most  original  man,  once,  lacking  other  means, 
being  alone  in  a  poor  dwelling,  arrested  a  haemorrhage  following  the 
extirpation  of  a  tumor  from  the  back,  by  means  of  the  tongs  which  he 
heated  in  the  stove.  A  knitting-needle,  stuck  in  a  piece  of  wood  or  a 
cork,  and  heated  at  the  lamp,  may  answer  the  purjx)se  of  the  hot  iron. 

A  remedy  which  not  only  equals,  but  occasionally  surpasses,  the 
hot  iron  in  its  effects,  is  liquor  ferri  sesquichlorati  •  this  forms  with 
the  blood  such  a  leathery,  adlierent  coagulum,  that  it  acts  excellently 
as  a  styptic.  To  apply  it,  you  press  a  piece  of  charpie,  moistened  with 
it,  firmly  against  the  wound ;  after  having  washed  off  the  blood  with  a 
sponge,  hold  it  there  from  two  to  five  minutes ;  you  will  thus  be  able 
to  arrest  quite  free  arterial  haemorrhage.  If  the  first  application  does 
not  succeed,  try  it  a  second  or  third  time ;  this  remedy  will  rarely  fail 
you ;  but  it  makes  a  slough,  behind  which  there  is  often  sanious  sup- 
puration mixed  with  gas- bubbles ;  hence  we  should  not  employ  this 
styptic  needlessly. 

The  application  oi puiik  and  blotting-paper  to  bleeding  wounds  is 
an  old  popular  remedy ;  the  punk  sticks  fast  to  the  blood  and  the  wound, 
if  the  bleeding  be  not  excessive ;  in  haemorrhages  at  all  fi-ee  it  is  useless 
without  simultaneous  compression  ;  occasionally  it  is  very  efl!icacious, 
and  is  highly  praised  by  some  surgeons.  Dry  charpie  pressed  firmly 
on  the  wound  has  the  same  effect,  according  to  my  experience. 

Other  haemostatics  are  oil  of  turpentine  and  aqua  JBlnelli^  in 
which  the  creosote  is  chiefly  efficacious ;  concerning  the  former  alone 
have  I  any  experience,  and  I  recommend  it  strongly ;  when  I  studied 
in  Gottingen,  it  was  also  specially  recommended  by  my  preceptor, 
/?a«m,  and  I  used  it  once  with  such  striking  benefit  in  a  doubtful  case 
that  I  have  a  certain  devotion  for  it.  It  is,  however,  an  heroic  remedy, 
not  only  because  application  of  turjoentine-oil  to  a  wound  induces 
severe  pain,  but  also  because  it  excites  severe  inflammation  in  the 
wound  and  its  vicinity.     I  will  relate  the   case  where  I  emjjlojed  it 


40  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

A  young,  feeble  woman  suffered,  after  confinement  for  many  months, 
from  an  extensive  suppuration  behind  the  right  breast,  between  the 
mammary  gland  and  the  fascia  of  the  pectoral  muscle ;  numerous  inci- 
sions had  already  been  made  through  the  breast,  and  about  its  circum- 
ference, to  give  free  access  to  the  pus  which  formed  in  such  quantities ; 
but  the  openings  soon  closed  again,  and  new  ones  had  to  be  made,  as 
the  wound  did  not  heal  from  below.  From  one  such  incision,  which  I 
made  quite  extensive,  severe  hasmorrhage  resulted,  blood  welled  up 
from  the  depth  of  the  abscess,  and  I  was  unable  to  find  the  bleeding 
vessel ;  it  flowed  continuously,  as  if  from  a  spring.  First,  I  filled  the 
cavity  with  charpie  and  applied  a  bandage ;  the  blood  soon  oozed 
through  this  dressing ;  I  removed  it  and  injected  ice-water  into  the 
various  openings ;  the  bleeding  moderated.  I  again  made  firm  compres- 
sion, and  the  haemorrhage  seemed  arrested.  I  had  scarcely  reached  my 
room  in  the  hospital  when  I  was  called  by  the  nurse,  because  the  blood 
again  oozed  through  the  dressing  ;  the  patient  had  fainted,  was  pale 
as  a  corpse,  and  the  pulse  was  very  small.  The  bandage  had  to  be 
removed  at  once.  I  now  thrust  pieces  of  ice  through  the  different 
openings  into  the  cavity  under  the  breast ;  still  the  bleeding  was  not 
arrested.  The  patient  went  from  one  fainting-fit  into  another,  the  bed 
flowed  with  blood  and  ice-water,  the  j^atient  lay  unconscious,  with  cold 
limbs  and  upturned  eyes,  the  nurses  constantly  trying  to  resuscitate  the 
patient  by  holding  ammonia  to  the  nose,  and  rubbing  the  forehead  with 
Cologne  water.  At  the  commencement  of  my  surgical  life,  unaccus- 
tomed to  quiet  and  presence  of  mind  in  such  scenes,  caused  by  my  own 
act,  I  shall  never  forget  this  situation.  I  thought  it  would  be  abso- 
lutely necessary  to  amputate  the  breast  at  once,  to  find  and  ligate  the 
bleeding  artery,  but  determined  to  make  one  more  attempt  with  oil 
of  turpentine.  I  soaked  a  few  wads  in  this  substance,  introduced 
them  into  the  wound,  and  the  bleeding  was  instantly  arrested.  The 
patient  soon  revived ;  the  turpentine,  which  was  left  in  twenty-four 
hours,  caused  intense  reaction  in  the  abscess  cavitj'^,  whose  walls  be- 
came detached.  Subsequent  active  granulation  induced  in  three  weeks 
a  cure  which  had  for  months  been  patiently  and  perseveringly  sought 
in  vain  by  physician  and  patient.  I  cannot  explain  to  you  how  bleed- 
ing is  arrested  by  oil  of  turpentine  and  creosote ;  they  do  not  cause 
particularly  firm  coagulation  of  the  blood ;  probably  the  intense  imta- 
tion  they  induce  excites  a  peculiarly  energetic  contraction  of  the  di- 
vided capillaries. 

You  will  rarely  see  styptics  employed  in  the  surgical  clinic ;  they 
are  rather  favorites  of  the  practising  physician,  who  is  not  accustomed 
to  ligate  arteries.     Where  we  can  ligate  or  compress,  we  should  not 


TRANSFUSION   OF   BLOOD.  41 

ase  styptics.  In  parenchymatous  bleeding  from  the  face,  ueck,  or 
perinaium,  we  may  resort  to  stj^i^tics  with  advantage,  if  it  makes  no 
difference  whether  the  wound  suppurates  subsequently ;  but,  if  the 
hasmorrhage  be  considerable,  and  styptics  fail,  subsequent  ligation  is 
much  more  difficult,  as  the  woxmd  is  often  terribly  smeared  up  by  the 
previous  applications. 

In  surgery  you  have  nothing  to  expect  from  the  internal  adminis- 
tration of  remedies  recommended  as  styptics.  Absolute  quiet,  keeping 
cool,  narcotics,  purgatives,  may  occasionally  be  of  great  assistance  in 
congestive  haemorrhages,  but  their  action  is  far  too  slow  for  the  bleed- 
ing that  we  have  to  deal  with  in  surgery. 

The  general  debility  from  profuse  hremorrhage  will,  of  course, 
be  most  effectually  combated  by  arresting  the  bleeding ;  but,  while 
doing  this,  you  may  have  the  assistants,  not  otherwise  employed,  try 
to  resuscitate  the  patient  by  smelling-salts,  sprinkling  with  water, 
etc.  You  should  not  yourself  join  in  these  attempts,  till  the  bleed- 
ing is  stopped ;  then  you  may  give  wine,  rum,  or  brandy,  warm  coffee, 
or  soup  ;  cover  the  patient  up  warmly  ;  let  him  take  a  few  drops  of  spir- 
its of  ether  or  acetic  ether,  and  smell  ammonia,  etc.  I  have  never  had  a 
patient  bleed  to  death  under  my  hands,  but  have  met  two  cases  where 
the  patients  died,  two  and  five  hours  after  extensive  operations, 
with  dyspnoea  and  spasmodic  contractions,  apparently  as  a  result  of 
the  great  loss  of  blood ;  these  cases  decided  me,  under  similar  cir- 
cumstances, to  inject  the  blood  of  a  healthy  person  into  the  veins  of 
the  bleeding  one.  This  operation,  which  is  called  transfusion,  is 
quite  ancient ;  it  originated  in  the  middle  of  the  seventeenth  cen- 
tury. After  the  world  had  been  for  a  time  astonished  at  its  boldness, 
it  was  laid  aside  and  derided,  but,  toward  the  end  of  the  last  century, 
it  was  again  drawn  from  the  shade  of  oblivion  by  English  physicians,  es- 
pecially the  obstetricians.  After  DieffenbacJi  had  made  some  attempts 
again  to  introduce  transfusion  into  Germany  without  success,  Mar- 
tin has  of  late  the  credit  of  again  calling  attention  to  it  as  a  mode 
of  saving  life,  while  Panum  has  exhaustively  treated  the  subject  in 
physiological  experiments.  Statistics  show  that  the  operation  was 
favorable  in  the  great  majority  of  cases,  and  was  very  easy  to  per- 
form. Although  formerly  lamb's  blood  was  successfully  injected  into 
man's  veins,  it  is  best  and  most  natural  to  choose  blood  from  a  young, 
healthy,  and  strong  human  being.  The  instruments  required  are  a 
knife,  forceps,  scissors,  a  fine  canula,  and  a  4-6  oz.  glass  syringe  to 
fit  it.  We  open  the  vein  of  a  healthy,  strong  young  man,  in  the  man- 
ner hereafter  to  be  described,  and  receive  first  about  four  ounces  of 
the  blood  in  a  rather  high  bowl,  standing  in  a  basin  full  of  blood-warm 
water;  the  blood,  flowing  into  the  bowl,  is  beaten  with  a  twirling 


42  SIMPLE   INCISED  WOUNDS   OF   THE   SOFT   PARTS. 

stick,  till  the  fibrine  is  separated.  While  this  is  being  done,  the  most 
perceptible  subcutaneous  vein  at  the  bend  of  the  elbow  of  the  patient 
is  to  be  exposed  by  an  incision  through  the  skin ;  then  two  silk  threads 
are  to  be  passed  under  it,  the  lower  one  is  drawn  on  without 
closing  it,  so  that  no  blood  may  escape  by  the  subsequent  fine  oblique 
incision  made  in  the  vein  by  the  scissors.  The  canula  is  passed  up 
into  the  now  gaping  opening  in  the  vein,  and  the  upper  thread  is 
crossed  over  it  without  being  tied ;  some  blood  should  escape  through 
the  canula,  so  as  to  fill  it  and  drive  out  the  air.  JNIeanwhile,  the  as- 
sistant has  completed  the  venesection  and  filtered  the  whipj^ed  blood 
through  a  fine  cloth ;  then  the  previously-warmed  syringe  is  to  be 
filled  with  the  blood, inverted  and  the  air  forced  out,  placed  firmly  in  the 
canula,  and  the  blood  injected  very  slowly.  Experience  has  taught 
that  it  is  not  advisable  to  inject  more  than  four  to  eight  ounces  of 
blood,  and  that  this  is  enough  to  recall  life.  We  should  never  empty 
the  syringe  entirely,  and  cease  at  once  if  the  patient  has  dj^spnoea. 
Wlaen  the  injection  is  comi^leted,  we  remove  the  ligatures  and  canula, 
and  treat  the  wound  as  after  venesection.  There  has  been  much  dis- 
pute, as  to  whether  or  not  it  is  necessary'-  to  remove  the  fibrine  from 
the  blood  to  be  injected.  PanwirCs  experiments  have  clearly  proved  that 
fibrine  is  not  necessary  in  resuscitation  by  transfusion,  and  that,  even 
with  the  greatest  care,  it  may  act  injuriously  by  clotting.  The  active 
element  in  this  operation  apjaears  to  be  the  introduction  of  blood-cor- 
puscles as  bearers  of  oxygen.  Possibly,  transfusion  has  a  still  wider 
future ;  at  all  events,  it  might  be  worth  while  to  try  it  in  excessive 
ansemia,  resulting  from  other,  sometimes  unknown,  causes,  even  al- 
though, according  to  Panuni's  excellent  observations,  the  blood  itself 
does  not  nourish,  but  is  only  the  bearer  and  forwarder  of  nourish- 
ment. The  experiments  made  by  Neudorfer,  during  the  last  Italian 
War,  on  the  wounded  who  had  become  anaemic  from  profuse  suppura 
tion,  had  no  brilliant  results,  it  is  true,  but  further  trials  should  be 
made  of  this  operation,  which  with  proper  care  is  not  dangerous. 

Hueter  has  studied  transfusion  most  thorough.ly  of  late  ;  he  rec- 
ommends injecting  beaten  and  filtered  venous  blood  into  an  artery 
(such  as  the  radial  or  posterior  tibial)  in  a  peripheral  direction,  just 
as  was  once  done  by  Von  Graefe.  As  Hueter  has  demonstrated  that 
this  arterial  transfusion  is  easier  than  the  venous,  it  deserves  the 
preference,  because  by  it  we  avoid  the  danger  of  pulmonary  emboli. 
No  abnormal  symptoms  occurred  where  Hueter  operated  on  the  hnnds 
and  feet  ;  but  I  doubt  if  it  would  often  be  possible  to  introduce  a 
canula  into  these  small  arteries  in  a  patient  bleeding  to  death  ;  in 
such  a  case  we  should  have  to  choose  the  brachial  arter}'. 

The  enormous  increase  of  bodily  temperature,  the  occurrence  of 


GAPING   OF   THE   WOUND.  43 

bloody  urine,  and  other  symptoms,  following  this  operation,  show 
that  it  has  a  very  decided  influence  on  the  physiological  action  of  the 
oro-anism.  As  this  operation  has  always  been  performed  in  vain  by 
myself  and  my  assistants,  I  am  much  less  in  favor  of  it  than  formerly, 
when  I  only  knew  it  from  the  accounts  of  others. 

I  cannot  here  enter  on  the  treatment  of  the  later  results  of  con- 
siderable hsemorrhages ;  it  will  be  evident  to  you  that,  in  general,  the 
chronic  effects,  the  deficient  formation  of  new  blood,  must  be  com- 
bated by  strengthening  and  nourishing  diet  and  medicines. 


LECTURE   lY. 

Ga[>lng  of  the  Wound. — Union  \j  Plaster.— Suture  ;  Interrupted  Suture  ;  Twisted  Su- 
ture. — External  Changes  perceptible  in  the  United  Wound. — Healing  by  First  In- 
tention. 

After  entirely  arresting  the  ha3morrhage  from  a  wound,  cleaning 
its  surface  mth  cold  water,  and  satisfying  yourself  of  its  depth,  and 
of  the  character  of  the  parts  divided,  in  doing  which  you  must  notice 
whether  a  joint,  or  one  of  the  cavities  of  the  body,  has  been  opened, 
a  large  nerve  divided,  or  a  bone  exposed  or  injured,  etc.,  you  will 
turn  5'our  attention  to  the  third  S}Tnptom  in  the  fresh  wound,  that  is, 
its  gaping.  On  division .  skin,  fascia,  and  nerves  Avill  separate,  partly 
from  their  own  elasticity,  partly  because  they  are  attached  to  the  mus- 
cles, which,  from  their  contractility,  shrink  together  immediately 
after  being  divided,  and  whose  cut  surfaces,  consequently,  especially 
in  transverse  wounds,  are  more  or  less  separated. 

At  first  we  shall  consider  only  those  incised  wounds  where  there  has 
been  no  loss  of  substance,  but  only  a  simple  division  of  the  soft  parts. 
For  such  a  wound  to  heal  quickly,  it  is  desirable  that  the  two  edges 
should  be  brought  exactly  together,  as  they  were  before  the  injury; 
to  accomplish  this,  we  make  use  of  strips  of  adhesive  plaster  or  of 
sutures. 

In  wounds  where  the  cutis  is  scarcely  divided,  as  so  often  happens 
in  the  common  incised  wounds  of  the  fingers,  Ave  may  use  isinglass- 
plaster  with  advantage.  It  consists  of  a  solution  of  ichthyocolla  in 
water,  mixed  with  a  little  spirits  of  wine,  painted  over  a  thin,  firm 
Bilk  stuff  or  paper ;  the  back  is  often  painted  Avith  tincture  of  benzom, 
which  giA'-es  the  plaster  a  pleasant  odor.     As  the  plaster  readil3  lois 


44  SIMPLE   IXCISED   WOUNDS   OF   THE   SOFT   PARTS. 

ens  under  moist  compresses,  it  is  often  advisable  to  paint  it  with  col- 
lodion, after  it  has  dried. 

Collodion  is  a  solution  of  gun-cotton  in  a  mixture  of  ether  and 
alcohol.  If  this  fluid  be  painted  over  the  plaster  and  the  skin  immedi- 
ately adjacent,  the  ether  quickly  evaporates,  and  a  fine  membrane  in- 
soluble in  water  remains,  often  puckering  up  the  skin.  A  further 
therapeutic  use  may  be  made  of  this  contractile  action  of  collodion, 
by  painting  it  on  the  inflamed  skin,  either  directly,  or,  still  better,  after 
covering  the  part  with  a  thin,  coarse-meshed  cotton-cloth  (gauze) ; 
this  causes  moderate,  even  pressure.  When  you  use  collodion  to 
fasten  the  plaster,  avoid  applj-ing  it  directly  to  the  wound ;  this  not 
only  causes  unnecessary  pain,  but  may  also  induce  inflammation  and 
suppuration  of  the  wound,  which  should  be  particularly  avoided. 

If  the  cutis  be  divided,  and  the  plaster  must  resist  any  considera- 
ble tension  in  keeping  the  edges  of  the  wound  together,  ichthyocolla- 
plaster  proves  insufficient,  and  adhesive  plaster  must  be  employed. 
Of  this  we  have  two  varieties,  besides  innumerable  modifications,  from 
attempts  to  make  it  cheaper  and  better.  Emplastrum  adhaisivum, 
emplastrum  diachylon  compositum,  our  common  adhesive  plaster,  con- 
sists of  olive-oil,  litharge,  resin,  and  turpentine.  While  it  is  fluid 
from  heat  it  is  painted  on  linen,  and  it  is  generally  used  in  strips,  which 
are  laid  over  the  wound,  and  hold  its  edges  together.  When  fresh, 
this  plaster  adheres  excellently,  but  loosens  after  a  time,  if  moist  com- 
presses be  applied  over  it.  Very  sensitive  skins  are  irritated  by  this 
plaster  if  it  is  frequently  applied ;  then  we  may  resort  to  the  other  adhe- 
sive plaster,  the  emplastrum  cerusscB  (emplastrum  adhajsivum  album), 
which  is  prepared  from  olive-oil,  litharge,  and  white  lead,  with  hot 
water.  This  plaster  adheres  less  firmly,  but  has  the  advantage  of 
smearing  the  lips  of  the  wound  less  than  the  yellow  plaster.  A  mix- 
ture of  equal  parts  of  the  two  plasters  lessens  the  objections  and  com- 
bines the  advantages. 

In  large  wounds  we  now  avoid  the  use  of  adhesive  plaster  more 
than  formerly,  and  in  its  place  employ  the  suture  more  commonly. 
When  we  wish  to  unite  wounds  by  the  suture,  we  generally  choose 
between  two  varieties,  the  interrupted  (sutura  nodosa)  and  the  twisted 
sutm-e  (sutura  circumvoluta).  There  is  some  truth  in  the  assertion 
that,  by  the  introduction  of  a  foreign  body,  such  as  a  thread  or  needle, 
we  maintain  constant  irritation  in  the  edges  of  the  wound,  but  this 
cannot  equal  the  great  advantage  obtained  by  the  certainty  of  ad- 
justment of  tlie  edges  of  the  wound  by  means  of  sutures.  Hence, 
except  adhesive  plaster,  almost  all  substitutes  for  the  suture,  va.  which 
ancient  and  modern  surgery  has  exhausted  itself,  after  being  fashion- 


UNION   OF  WOUNDS— SUTURES.  45 

able  for  a  time,  have  been  thrown  aside.  The  suture  has  not  yet 
been  dropped,  and  probably  never  will  be,  any  more  than  ligation. 

Tbere  are  certain  parts  of  the  body,  as  the  scalp,  hands,  and  feet, 
where  we  try  to  avoid  sutures,  because  there  certain  inflammatory 
processes,  which  have  often  been  ascribed  to  the  suture,  readily  assume 
a  dangerous  character;  but  I  think  there  is  a  good  deal  of  prejudice 
in  this.  Wounds  of  the  head  are  especially  prone  to  cause  inflamma- 
tions of  the  skin  and  subcutaneous  tissue  ;  extensive  statistics  have 
never  shown  whether  this  tendency  is  particularly  increased  by  the 
irritation  from  sutures.  Tliere  are  many  articles  of  faith  handed 
down  from  preceptor  to  pupil,  from  one  text-book  to  anothei" ;  many 
of  them  are  a  sort  of  Hippocratic  traditions,  full  of  practical  truth  ;  to 
these  I  pay  full  respect ;  others  are  based  on  accidental  observations 
and  consequent  judgments  ;  among  the  latter,  I  class  the  objection  to 
sutm'es  in  scalp-wounds.  Reviewing  my  own  experience,  I  remember 
more  cases  of  inflammation  following  wounds  where  no  sutures  were 
introduced  than  where  they  were.  It  is  very  important,  however,  at 
once  to  recognize  inflammations  beginning  in  the  head,  and  to  remove 
the  sutures.  The  amount  of  gaping  and  the  forms  of  the  wound  (e.  g., 
a  flap-wound  or  not)  at  once  show  the  necessity  for  sutures.  One 
would  never  take  any  unnecessary  trouble  in  introducing  sutures,  un- 
less urged  by  excess  of  surgical  zeal ;  but  where,  for  the  reasons  above 
given,  adhesive  plaster  will  not  answer,  we  should  employ  sutures. 

For  the  interrupted  suture  we  use  surgical  needles  and  silk  thread 
or  wire.  Surgical  needles  differ  from  ordinary  ones,  in  having  a  lance- 
shaped,  ground  point,  which  pierces  the  skin  more  readily  than  the 
round  point  of  a  sewing-needle  ;  they  are  also  of  somewhat  softer 
steel  than  English  sewing-needles,  so  that  they  do  not  spring  so 
much.  Their  thickness  and  length  vary  greatly,  according  as  we 
wish  to  apply  a  strong  thread  deeply  Avhere  the  edges  of  the  wound 
are  tense,  or  only  to  use  a  fine  thread  to  bring  the  edges  together  ex- 
actly. All  needles  should,  however,  have  a  good-sized  eye,  so  that  we 
may  not,  like  a  tailor,  lose  time  in  threading  them,  but  do  so  readily 
and  quickly.  The  needle  ma}-^  be  either  straight  or  curved.  The 
curve  should  vary  with  the  locality  Avhere  we  wish  to  sew ;  for  in- 
stance, very  fine,  strongly-curved  needles  are  required  for  sewing  about 
the  inner  canthus  of  the  eye ;  large,  strongly-curved  needles  are 
needed  for  sewing  up  a  perinaeum,  ruptured  during  labor,  etc.  The 
curvature  may  either  be  in  the  whole  needle  or  only  at  the  pointed 
end ;  for  instance,  for  certain  operations,  it  is  shaped  like  a  fish-hook  ; 
the  variety  is  very  great.  For  sewing  such  wounds  as  usually  present 
themselves  in  practice,  you  need  only  a  few  fine  and  coarse  straight 
and  variously-curved  needles. 


46  SIMPLE   INCISED  WOUNDS   OF   THE   SOFT   PARTS. 

The  thread  is  usually  of  silk,  whose  coarseness  corresponds  to  the 
size  of  the  needle.  Formerly  I  always  sewed  with  the  red  German 
silk,  which  has  long  been  used  for  tliis  purpose  ;  but  in  England  I 
found  a  sort  of  undyed,  strongly-twisted  silk,  which,  even  when  very 
fine,  is  so  strong  that,  with  thread  as  fine  as  a  hair,  we  may  sew  up 
wounds  and  draw  them  together.  Moreover,  this  silk  imbibes  so  little 
moisture  that  it  may  lie  for  days  in  the  woimd  without  swelling  or  ir- 
ritating. Now  I  use  only  this  so-called  Chinese  silk.  Another  mate- 
rial for  sutures  has  been  lately  used  in  England  and  America,  viz., 
silver  or  iron  wire.  It  must  be  very  fine  and  soft ;  the  iron  wore  for  this 
purpose  is  well  annealed.  The  trial  of  this  material  was  first  induced 
by  the  long-known  fact  that,  when  metals  were  introduced  under  the 
skin  or  anywhere  in  the  body,  they  usually  excited  no  suppuration, 
but  the  parts  often  healed  over  them.  Hence,  it  was  thought  that 
the  inflammations  often  occurring  at  the  points  of  suture  might  be 
avoided  by  using  metal  instead  of  the  animal  substance  silk.  In 
truth,  it  cannot  be  denied  that  this  suppuration  is  less  apt  to  occur 
from  metal  than  from  silk  thread,  still  exjDeriinents  of  /Simon  have 
shown  that  the  suppuration  from  sutures  depends  greatly  on  the  thick- 
ness of  the  thread.  From  my  own  experience  I  can  affirm  that  fine 
silk  threads  cause  as  little  suppm-ation  along  the  course  of  the  suture, 
and  may  heal  in,  just  as  well  as  metal  ones. 

We  come  now  to  the  application  of  the  interrupted  suture.  You 
do  it  as  follows  :  with  a  toothed  forceps  you  first  seize  one  lip  of  the 
wound ;  pass  the  needle  through  the  skin,  about  two  lines  from  the 
edge,  as  deep  as  the  subcutaneous  tissue,  and  bring  it  out  through  the 
wound ;  now  seize  the  other  lip  of  the  Avound  with  the  forceps  and 
pierce  it  from  the  wound  up  toward  tlie  skin,  exactly  opposite  the 
first  point  of  entrance,  then  draw  the  thread  through  and  cut  it  off, 
leaving  both  sides  long  enough  to  tie  readily  in  a  knot.  Now  make 
a  simple,  or,  if  the  tension  of  the  borders  of  the  wound  be  great,  a 
surgeon's  knot,  and  draw  it  tight,  seeing  that  the  edges  of  the  wound 
are  in  exact  apposition ;  then  make  a  second  knot,  and  cut  off  both 
threads,  close  to  the  knot,  so  that  no  long  ends  of  thread  may  get  in 
the  wovuid. 

Should  you  desire  to  use  wire,  you  thread  it  as  you  do  the  silk  on 
the  needle,  draw  a  short  portion  through  the  eye  and  bend  it,  then 
make  the  suture  as  above  described.  Wlien  the  wire  is  very  soft,  we 
can  tie  a  knot  with  it  nicely,  just  as  with  a  silk  thread;  still,  the 
whole  of  this  manipulation  is  much  less  pleasant  with  wire  than  with 
silk  thread,  and  on  closing  the  knot  the  border  of  the  skin  is  readily 
displaced,  or  there  may  be  twists,  that  render  the  hold  less  secure ; 


UNION   OF  WOUNDS.  V47 

this  is  especially  apt  to  happen  with  our  German  wire,  which  has  not 
yet  attained  the  softness  of  the  English.  The  pleasantest  wires  are 
those  made  of  a  mixture  of  gold  and  silver  and  of  platinum,  of  which 
very  fine,  pliable,  and,  at  the  same  time,  firm  wire  may  be  made.  [Very 
nice  wire  is  made  of  lead,  and  it  is  supposed  by  some  to  be  an  advan- 
tage that  this  will  break  if  the  parts  should  swell  excessively.]  Still, 
how  ridiculous  it  would  be  to  try  to  substitute  these  expensive  articles 
for  ordinary  silk,  by  which  millions  of  wounds  have  been  healed  excel- 
lently, and  will  be  in  future  !  I  pass  over  the  many  newly-recommend- 
ed modes  of  fastening  the  wire  by  knots  or  twisting ;  they  show  that 
even  those  who  advocate  metallic  sutures  have  found  some  trouble  in 
fastening  the  knot.  I  first  make  a  simple  knot,  draw  it  together, 
make  two  or  three  short  twists,  and  cut  off  the  ends  close  to  the 
twisted  part.  Wire  cuts  the  edges  of  the  wound,  just  as  silk  does,  if 
it  be  very  fine. 

I  have  rarely  found  the  little  objections  to  silk  sutures  sufficiently 
annoying  to  make  me  replace  them  by  metal  sutures.     Beginners 
generally  err  in  making  sutures  too  tight ;  this  constricts  the  edges 
of  the  wound.     When  they  swell,  as  they  mostly  do,  this  constriction 
is  rarely  enough  to  kill  tlie  tissue  at  once,  but  causes  inflammation 
with  redness  and  suppuration  about  the  puncture,  which  may  spread 
and  impede  healing  of  the  wound  if  the  sutures  be  not  removed  in  time. 
Straight  needles  may  be  best  introduced  with  the  fingers;  but 
curved  needles,  especially  Avhen  they  are  small  or  the  wound  deeply 
seated,  are  introduced  better  and  more  certainly  by  means  of  a  needle- 
holder.     There  are  numbers   of  these  ;    I  am  in  the  habit  of  using 
DieffenbacK's.     It  consists  of  a  forceps  with  short,  thick  blades,  be- 
tween which  we  hold  the  needle  firmly  and  securely,  and  introduce  it 
through  the  skin  in  the  direction  of  its  curvature.     This  perfectly  sim- 
ple instrument  suffices  for  almost  all  cases,  and  in  good  hands  is  sur- 
passed by  no  instrument  for  security  in  holding  and  introducing  the 
needle.     Complicated  instruments  are  especially  suited  for  unskilful 
surgeons,  says  Dieffenhach^  in  the  unparalleled  introduction  to  his  Ope- 
rative Surgery ;  not  the  instrument,  but  the  hand  of  the  surgeon,  should 
operate.     Practice  and  habit  render  this  or  that  instrument  indispen- 
sable.    Thus   some  find  it  complicated  and  inconvenient  to  seize  the 
lips  of  the  wound  with  forceps,  as  I  taught  you,  although  this  is  bet- 
ter than  holding  them  with  the  fingers ;  for  me,  the  latter  would  be 
very  inconvenient.     In  this  matter  any  one  may  do  as  liis  habits  and 
inclination  lead  him.     When  I  have  to  sew  some  deep  part — as  the 
velum,  rectum,  or  vagina — I  always  use  needles  w^ith  handles. 

Of  course  the  number  of  sutures  to  be  applied  depends  on  the 


48  SIMPLE   IXCISED   WOUXDS   OF   THE   SOFT   PARTS. 

length  of  the  wound  ;  generally  sutures  half-an-inch  apart  suffice,  but 
where  perfect  apposition  and  small  cicatrices  are  very  desirable,  as  in 
wounds  of  the  face,  they  must  be  closer,  and  should  alternate  between 
coarse  ones  at  a  distance  from  the  edge  of  the  wound,  and  fine  ones 
enclosing  but  a  small  portion  of  the  edge. 

The  second  variety  of  suture,  twisted  or  hare-lip  suture,  is  made  by 
passmg  a  long  pm  Avith  a  lance-shaped  jDoint  through  the  flaps  of  the 
wound,  and  passing  a  strong  cotton  or  silk  thread  around  it,  as  I  now 
show  you.  You  take  the  thread  in  both  hands,  lay  it  parallel  to  and 
immediately  over  the  pin,  that  is,  transversely  to  the  wound,  pass  it 
under  the  two  ends  of  the  pin  from  above,  and  draw  on  it,  so  as  to 
approximate  the  edges  of  the  wound  exactly  (this  is  the  so-called 
Nulltour) ;  now  you  change  the  threads  to  the  other  hands,  and,  with 
the  right  thread  in  the  left  hand,  pass  around  the  left  end  of  the  pin 
from  above  downward,  and,  with  the  left  thread  in  the  right  hand,  do 
tiie  same  for  the  right  end  of  the  pin  j  you  change  the  threads  again 
and  make  four  to  six  similar,  so-called  figure  of  eight  turns ;  then  tie 
a  double  knot  and  cut  the  ends  off  close ;  then  cut  off  the  ends  of  the 
pin  to  a  proper  length,  so  that  they  may  not  press  on  the  skin,  but  not 
so  short  as  to  prevent  their  being  readily  withdrawn  subsequently. 

There  are  a  great  number  of  other  sutures,  which  for  tlie  most 
part  are  only  of  historical  interest,  and  which  we  here  pass  over ; 
some  peculiar  forms  of  sutuie  will  be  treated  in  special  surgery,  under 
wounds  of  the  different  parts,  as  in  wounds  of  the  intestine. 

Where  are  the  advantages  of  the  tAvisted  over  the  interrupted 
suture  ?  and  when  do  you  employ  it  ?  These  indications  may  be  re- 
duced to  two  factors,  so  that  you  will  consider  the  interrupted  suture 
as  the  simpler  and  more  common.  The  twisted  suture  is  preferable — 
1.  When  the  flaps  of  the  Avound  are  very  tense ;  2.  When  the  skin- 
flaps  to  be  united  are  very  thin  and  without  support — in  short,  where 
the  lips  of  the  wound  have  a  tendency  to  roll  in.  The  needle,  remain- 
ing in  position  in  both  cases,  renders  the  suture  more  secure  and  firm ; 
the  needle  serves  as  a  sort  of  subcutaneous  splint  for  the  edges  of  the 
skin  ;  they  are  supported  by  it,  and  are  also  held  more  secui-ely  by  the 
folds  of  thread  on  the  outside.  In  many  cases,  in  applying  sutures  in 
the  face,  the  interrupted  and  twisted  sutures  are  applied  alternately ; 
the  latter  serve  as  supports  and  to  resist  tension,  the  former  to  in- 
duce more  exact  union  of  the  edges  of  the  loound. 

When  the  bleeding  has  been  stopped  and  the  wound  united,  all 
has  been  done  that  is  at  first  necessary.  Now  let  us  observe  what 
takes  place  in  the  closed  wound. 


UNION   OF  WOUNDS.  49 

Immediately  after  being  united,  the  edges  of  the  wound  are  gener- 
al ly  white,  from  the  pressure  exercised  by  the  sutures  as  they  com- 
press the  capillaries ;  rarely  the  borders  of  the  wound  are  dark  blue ; 
this  always  indicates  great  impediment  to  the  return  of  blood  through 
the  veins,  due  to  a  loss  of  part  of  the  blood-vessels.  It  is  evident 
that  the  communication  between  arteries  and  veins  may  be  greatly 
disturbed  by  the  division  of  a  large  number  of  capillaries,  so  that  at 
some  point  in  the  border  of  the  wound  the  vis  a  tergo  of  the  venous 
stream  shall  be  insufficient.  On  the  whole,  this  dark-blue  color  of  the 
flaps  of  the  wound  is  rare ;  it  either  disappears  spontaneously  or  a 
small  portion  of  the  lip  of  the  wound  dies,  a  symptom  to  which  we 
shall  retvirn  when  si^eaking  of  contused  wounds,  in  which  it  is  quite 
common. 

Even  after  a  few  hours  you  find  the  borders  of  the  wound  slightly 
swollen  and  occasionally  bright  red;  this  redness  and  swelling  are 
often  absent  (especially  where  the  epidermis  is  thick),  but  occasionally, 
according  to  the  extent  and  depth  of  the  wound  and  tension  of  the 
skin,  it  spreads  from  two  or  three  lines,  or  to  as  many  inches,  around 
the  wound ;  the  usual  so-called  local  reaction  about  the  wound  takes 
place  in  this  space.  The  wound  pains  slightly,  especially  on  being 
touched.  All  this  may  be  best  seen  in  children  and  women  with 
delicate  skin.  About  wounds  of  the  face,  especially  of  the  eyelids, 
we  often  notice  extensive  oedema  in  twenty-four  hours;  this  fre- 
quently terrifies  the  friends,  but  is  usually  free  froin  danger. 

In  a  considerable  number  of  cases,  if  the  sutures  be  not  too  tightly 
applied,  the  edges  of  the  wound  appear  unchanged  not  only  at  the 
time,  but  till  the  cure  is  complete.  But  often  enough  the  wound 
shows  the  cardinal  symptoms  of  inflammation  ;  pain,  redness,  swell- 
ing, and  increased  heat,  of  which  you  may  satisfy  j^ourself  by  placing 
your  finger  on  the  parts  about  the  wound,  then  on  a  distant  part  of 
the  body.  The  process  going  on  at  the  wound,  and  ending  in  the 
union  of  its  edges,  comes  under  the  combination  of  morphological  and 
chemical  metamorphoses  comprised  by  the  name  inflanitnation,  and, 
in  the  case  under  consideration,  would  be  termed  traumatic  wflain- 
rnatio7i,  that  is,  an  inflammation  caused  by  an  injury  (rpavjxa). 

As  a  rule,  these  local  symptoms  have  reached  their  height  in 
twenty-four  hours;  if  by  that  time  they  have  not  exceeded  the  above 
bounds,  3'ou  consider  the  process  as  taking  a  normal  course.  Tt  is  a 
marhed  peculiarity  of  traumatic  inflammation,  that  ^  in  a  pure  form, 
it  is  strictly  limited  to  the  borders  of  the  loound,  and  does  not  exteyid 
without  special  cause.  It  is  not  unusual  for  these  symptoms  to  remain 
at  the  same  height  the  second  or  even  the  third  day  ;  but  by  the  third 
or  fifth  day,  the  redness,  swelling,  pain,  and  increased  temperature, 
5 


50  SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS 

should  have  disappeared  mostly  or  entirely.  If  the  symptoms  still 
increase  the  second,  third,  and  fourth  days,  or  if  some  of  them,  as  se- 
vere pain,  and  great  swelKng,  recur  at  this  time,  or  if  they  remain  at 
the  same  point  to  the  fifth  or  sixth  day,  it  is  a  sign  that  the  course 
differs  in  some  way  from  the  normal.  This  \vill  be  especially  evident 
from  the  general  condition  of  the  patient.  The  whole  body  reacts  to 
an  irritation  of  one  part  of  it,  not  in  a  perceptible  manner,  in  small 
wounds,  it  is  true.  We  shall  refer  to  this  general  reaction  at  the  close 
of  this  chaiDter.  At  present,  we  shall  consider  exclusively  the  condi- 
tion of  the  wounded  part. 

The  third  day,  often  indeed  on  the  second,  you  may  carefully  re- 
move the  pins  of  the  twisted  suture,  provided  you  have  also  applied 
interrupted  sutures  ;  this  is  best  done  by  seizing  the  needle  with 
DleffenhacJi's  needle-holder,  and  rotating  it  gently,  while  fixing  the 
twisted  threads  with  one  finger.  The  threads  usually  remain  as  a 
sort  of  clamp  on  the  wound,  to  which  they  are  attached  by  dried 
blood  ;  they  subsequently  loosen  spontaneously  ;  by  forcibly  detach- 
ing the  thread,  you  would  unnecessarily  strain  the  wound,  and  possi- 
bly tear  apart  the  freshly-united  edges.  If  at  this  time  we  carefully 
feel  the  edges  of  the  wound — if  the  oedema  has  subsided — we  find  them 
rather  firmer  than  parts  around  ;  this  state  of  Jinn  infiltration  sooner 
or  later  disappears. 

When  you  have  apj^lied  many  stitches,  you  may  remove  some  of 
them,  that  have  little  to  hold,  on  the  third  day ;  others,  on  the  fourth 
and  fifth.  At  the  tensely-stretched  parts  of  the  skin  it  is  well  to  leave 
a  few  threads  for  eight  days  or  more,  or  even  leave  them  till  they  cut 
through  the  flaps  of  the  wound,  provided  it  can  do  any  good  to  hold 
together  the  edges  of  tlie  wound,  which  may  be  gaping  open.  Should 
the  inflammation  quickly  exceed  the  normal  amount,  we  must  remove 
the  sutures  earlier,  so  that  they  may  not  increase  the  irritation ;  not 
unfrequently  blood,  that  is  decomposing  or  mixed  with  pus,  at  the 
bottom  of  the  wound,  is  the  cause  of  the  unusual  irritation. 

In  removing  the  interrupted  suture,  you  should  take  the  following 
precautions  :  cut  the  thread  on  one  side  of  the  knot,  where  you  can 
most  readily  introduce  the  thin  blade  of  the  scissors  without  stretching 
the  wound ;  then  seize  the  thread  at  the  knot  with  a  dissecting  for 
ceps,  and  draw  it  out  toward  the  side  where  it  was  divided,  so  as  not 
to  separate  the  edges  of  the  wound  by  the  traction. 

Should  you  think  that,  after  removing  the  suture,  the  union  of  tne 
wound  is  still  too  weak  to  prevent  its  gaping,  you  may,  by  applying 
strips  of  ichthyocolla-plaster  transversely  over  the  wound,  between  the 
points  where  the  sutures  were,  and  fastening  the  ends  (not  the  part 


UNION   OF  WOUNDS.  61 

over  tlie  wound)  with  collodion,  give  support  enough  to  prevent  ten- 
sion of  the  flaps  of  the  wound,  such  as  unavoidably  occurs  in  changes 
of  expression  in  the  face. 

In  fi-om  six  to  eight  days,  most  simple  incised  wounds  have  adhered 
(irmly  enough  to  require  no  further  support ;  indeed,  in  many  cases, 
this  is  the  case  by  the  second  or  fourth  day.  If,  in  the  course  of  the 
following  days,  the  dry  blood  about  the  wound  be  carefully  washed 
off,  the  young  cicatrix  appears  as  a  fine  red  stripe,  a  scarcely  visible 
fine  line.     This  process  of  heaHng  is  called  healing  hy  first  intention. 

In  the  course  of  the  subsequent  months,  the  cicatrix  loses  its  red- 
ness and  hardness,  and  finally  becomes  perceptibly  whiter  than,  and  as 
soft  as,  the  skin  ;  so  that  for  years  it  may  be  recognized  as  a  fine  white 
line.  It  often  disappears  almost  entirely  after  some  years.  Some  of 
you,  who  left  the  university  with  many  still  %'isible  cicatrices  on  the 
face,  may  hope  that  they  will  be  scarcely  visible  in  six  or  eight  years, 
when  the  Philistine  visage  will  become  you  less  than  it  does  the  stu- 
dent.    Tempera  mutantur  et  nos  mutamur  in  illis. 


62  SIMPLE  INCISED   WOUNDS   OF   THE   SOFT  PARTS. 


LECTURE    V. 

The  more  Minute  Changes  in  Healing  by  the  First  Intention. — Dilatation  of  Vessels  in 
the  Vicinity  of  the  Wound. — Fluxion. — Different  Views  regarding  the  Causes  of 
Fluxion. 

Gbntlemeist  :  You  are  now  acquainted  with  the  changes,  visible 
to  the  naked  eye,  that  take  place  in  the  wound  while  it  is  healing  ; 
let  us  now  try  to  see  what  occurs  in  the  tissues  from  the  time  of 
wounding  till  the  formation  of  the  cicatrix.  For  a  long  time,  at- 
tempts have  been  made  to  study  and  know  these  changes  more 
thoroughly,  by  making  wounds  in  animals,  and  examining  them 
at  the  different  stages ;  but  it  is  only  the  most  exact  microscopic 
examination  of  the  tissue,  and  the  direct  observation  of  the  changes 
after  wounding,  that  have  enabled  us  to  give  a  description  of  the 
process  of  healing.  I  shall  attempt  to  give  you  a  brief  resume  of 
the  result  of  these  investigations,  which,  until  recently,  I  have  made 
my  special  study. 

[You  will  remember  that  I  tried  to  explain  to  you  the  significance 
of  traumatic  inflammation  as  an  accidental  complication  of  the  in- 
jury and  of  the  healing  of  wounds.  It  is  not  long  since  this  view 
began  to  gain  ground;  previous  observers  could  not  imagine  wounds 
healing  without  inflammation,  and  their  observations  were  made  on 
tissues  in  a  state  of  traumatic  inflammation  experimentally  induced. 
Hence  it  is  diflicult  to  separate  the  phenomena  due  to  healing  of  the 
wound  from  those  forming  part  of  the  inflammation.  At  all  events, 
observation  of  the  healing  of  wounds  first  gave  a  clear  insight  into 
the  nature  of  inflammation,  and  we  may  follow  its  course  from  this 
point  of  view.] 

The  interesting  results  thus  arrived  at  have  in  a  great  measure 
brought  it  about  that  by  "  inflammation  "  we  now  mean  generally  the 
series  of  changes  which  we  perceive  on  microscopic  examination.  Of 
late  we  are  accustomed  to  consider  these  morphological  processes  as 


SIMPLE  INCISED   WOUNDS  OF   THE   SOFT  PAKTS.  53 

the  essential  part  of  the  inflammation,  and  to  term  their  occurrence 
and  typical  course  the  ''  inflammatory  process."  I  would  not  weaken 
your  interest  in  these  things  at  the  outset ;  but  the  prevailing  tenden- 
cies render  it  necessary  for  me  to  call  j'our  attention  to  the  fact  that 
(as  in  all  organic  growth,  and  in  eacli  transformation  of  the  tissues 
of  the  body)  form  is  always  the  product  of  chemical  or  physical 
power  inherent  in  the  material  supplied ;  the  inflammatory,  like 
every  other  physiological  process,  is  chemico-physiological ;  this  we 
never  see,  even  with  the  best  microscopes ;  we  merely  perceive  the 
results  of  its  action.  These  results,  destruction  and  new  formation  of 
tissue,  have  something  peculiar  in  their  typical  course ;  but  they  vary 
as  widely  as  life  and  death ;  the  tissue  may  die  suddenly  or  not  for 
years  ;  of  two  neoplasia  of  the  same  structure,  one  may  fonn  in  a  few 
days,  the  other  may  require  months ;  very  different  causes  may  induce 
very  similar  new  formations.  But  I  dread  confusing  you,  if  I  enter 
further  into  the  difliculties  always  arising  when  we  speak  of  inflam- 
mation in  general.  So  let  me  go  at  once  into  detail ;  and  we  will 
hereafter  return  to  the  general  question  of  inflammation. 

The  changes  after  injury  of  the  different  tissues  are  particularly 
seen  in  the  vessels,  in  the  injured  tissue  itself,  and  in  its  nerves.  The 
influence  of  the  latter  on  the  process  is,  however,  so  obscure,  that  we 
shall  not  consider  it.  We  shall  at  once  dismiss  as  unanswerable  the 
question,  whether  the  finest  nutrient  (vasomotor)  nerves,  which  lose 
themselves  in  the  different  tissues  (for  the  question  can  only  arise  con- 
cerning these),  have  any  direct  influence  on  the  changes  occurring  in 
the  tissues,  and  in  the  vessels  themselves  ;  and  the  rather  so,  as  the 
ends  of  the  nerves  have  only  been  certainly  recognized  in  a  few  parts 
of  the  body,  while  for  other  parts  it  is  entirely  unknown  how  the  nu- 
trient nerves  act,  and  what  relation  they  have  to  the  capillary  vessels. 
You  will  have  already  had  your  attention  called  to  the  imaginable  pos- 
sibilities and  probabilities  on  this  point,  in  the  lectures  on  physiology 
and  general  pathology.  Hence,  if  we  say  but  little  about  the  nerves 
in  what  follows,  it  is  because  we  know  little  of  their  action  in  this 
special  process,  not  because  we  wish  to  deny  their  influence. 

Let  us  first  consider  the  simplest  tissue ;  let  us  suppose  a  vertical 
section,  through  the  connective  tissue,  with  a  closed  capillary  system 
at  the  surface  of  the  skin,  magnified  300-400  times.  Here  jon  have 
a  diagram  of  such  a  system. 

Let  there  be  an  incision  down  through  the  tissue ;  the  capillaries 
bleed,  the  bleeding  soon  ceases,  the  woimd  is  accurately  united.  Now 
what  takes  place  ? 

The  blood  coagulates  in  the  capillaries  as  far  as  the  next  branches, 


54 


UNION  OF  WOUNDS. 


CO  the  next  points  of  intersection  of  the  capillary  net-work.     Some  co- 
agulated blood  usually  remains  also  between  the  flaps  of  the  wound; 


Fig.  1. 


Diagram  of  connective  tissue,  with  capillaries.    Ma^ified  300-400. 

we  have  omitted  this  in  Fig.  2,  so  as  to  have  the  simplest  possible  rep- 
resentation of  the  changes.  Of  the  channels  for  the  circulation  in  our 
diagram,  some  have  become  impassable ;  the  blood  must  accommodate 
itself  to  the  existing  by-paths — of  course  this  takes  place  under  a 
heavier  arterial  pressure  than  previously ;  this  pressure  is  greater  the 
greater  the  obstruction  to  the  circulation,  and  the  less  numerous  the 
by-paths  (of  the  so-called  collateral  circulation).  The  result  of  this 
increased  pressure  is  the  distention  of  the  vessels  (which,  however,  is 
usually  much  greater  than  could  be  represented  in  the  diagram),  hence 
the  redness  about  the  wound,  and  to  some  extent  also  the  swelling. 
But  the  latter  also  has  another  cause :  the  more  the  capillary  walls 
ftre  distended,  the  thinner  they  become  ;  if  under  the  ordinary  press- 
ure, with  normal  thickness  of  their  walls,  they  permit  blood  plasma 
to  pass  to  nourish  the  tissues,  now  under  increased  pressure,  more 
plasma    than  normal  will   pass    through   the  walls,  wliich    saturates 


SIMPLE   INCISED  WOUNDS   OF   THE   SOFT   PARTS. 

Fio.  2. 


55 


Diagram  of  incision. — Capillaries  closed  by  bloocl-clot    Collateral  distention.    Mag 

nifled  300^W0. 


tlie  injured  tissue,  and  which  the  latter  absorbs  by  its  power  of 
swelling. 

This  is  a  brief  explanation  of  the  perceptible  changes  in  the 
borders  of  the  wound,  the  redness  and  increased  heat  caused  by  the 
rapid  development  of  the  collateral  circulation,  by  which  more  blood 
flows  through  the  vessels  nearer  the  surface ;  the  swelling  is  caused 
by  the  distention  of  the  vessels  and  swelling  of  the  tissues,  which 
again  induces  slight  compression  of  the  nerves,  and  this  excites  some 
pain. 

This,  as  it  seems  to  me,  very  simple  mechanical  explanation,  w^ould 
be  much  more  valuable,  if  it  fully  explained  the  whole  subsequent 
course,  and  could  be  applied  to  all  inflammations,  which  are  not  of 
traumatic  or  mechanical  origin.  But  this  is  not  the  case.  Neithei 
the  great  vascular  distention  that  occurs  some  time  after  injury,  that 
shows  itself  in  extensive  redness  around  the  wound,  nor  the  capillary 
dilatation  that  exists  from  the  first  in  idiopathic  inflamimations,  can  be 
referred  to  purely  mechanical  causes. 


5Q  UNION  OF  WOUNDS— IRRITATION. 

If  the  disturbance  of  circulation  through  the  incision  be  not  ex- 
tensive,  it  passes  off  very  rapidly ;  these  so-called  ^assewe  hypercBmias 
are  not  exactly  inflammations  ;  their  extent  accurately  corresponds  to 
the  mechanical  conditions,  while  in  regular  inflammations  the  redness 
often  extends  far  beyond  the  point  where  the  circulation  is  mechani- 
cally impaired.  We  do  not  call  it  inflammation  till  irritation  of  the 
tissues  accompanies,  or  in  fact  arises  from,  the  capillary  distention. 
Such  irritations,  causing  dilatation  of  the  capillaries,  are  numerous  ; 
we  shall  here  speak  only  of  the  mechanical  ones.  You  now  see  my 
ocular  conjunctiva  of  a  pure  bluish  white,  like  that  of  any  normal  eye. 
Now  I  rub  my  eye  till  it  weeps,  and  the  conjunctiva  becomes  reddish  ; 
perhaps  with  the  naked  eye  you  may  see  some  of  the  larger  vessels 
— with  a  lens  you  will  also  see  the  finer  vessels,  full  of  blood.  After 
five  minutes  at  most,  the  redness  has  entirely  disappeared.  Look  at 
an  eye  where  a  small  insect  has  accidentally  gotten  under  the  lid,  as 
so  often  happens  ;  the  person  rubs,  the  eye  weeps  and  becomes  quite 
red ;  if  the  insect  be  removed,  in  half  an  hour  you  will  probably  see 
nothing  noticeable  about  the  eye.  Here  you  have  the  simplest  obser- 
vation how  vessels  dilate  on  irritation,  and  empty  again  soon  after 
the  cessation  of  the  irritation.  AVhat  is  the  immediate  cause  of  this 
symptom  ?  Why  do  not  the  vessels  contract  instead  of  dilating  ? 
These  questions  are  as  difiicult  to  answer  as  the  observation  is  easy 
to  make,  and  to  repeat  innumerable  times,  with  the  same  result.  The 
fact  itself  has  been  known  as  long  as  man  has  observed;  the  old  say- 
ing "  ubi  stimulus  ibi  affluxus  "  refers  to  this.  The  increased  flow  of 
blood  is  the  answer  of  the  vascular  part  to  the  irritation. 

Of  late,  the  process  inducing  this  redness  is  called  active  hy 
'permmia  or  active  congestion.  Virchoic  took  up  the  old  name,  and 
made  ''^fluxion  and  congestion  "  again  popular. 

Assisted  by  your  knowledge  of  general  pathology,  you  will  now 
perceive  that  it  is  desirable  to  give  a  theoretical  explanation  of 
symptoms  which,  through  all  time,  have  formed  one  of  the  most  im- 
portant objects  of  consideration  in  medicine,  particularly  as  the  pro- 
cess of  inflammation  is  always  considered  as  closely  allied  to  this  ac- 
tive congestion,  or  indeed  even  considered  as  always  a  sequent  of  the 
latter.  Astley  Cooper^  a  celebrated  English  surgeon,  whose  works 
you  will  read  with  pleasure,  when  yow.  take  up  the  study  of  mono- 
graphs, a  thoroughly  practical  surgeon,  begins  his  lectures  on  sur- 
gery in  the  following  words :  "  The  subject  of  this  evening's  lec- 
ture is  irritation  ;  which,  being  the  foundation  of  surgical  science,  you 
must  carefully  study,  and  clearly  understand,  before  you  can  expect  to 
know  the  principles  of  your  profession,  or  be  qualified  to  practise  it 
creditably  to  yourselves,  or  with  advantage  to  those  who  may  place 
tl)emselves  under  vour  care." 


UNION  OF  WOUNDS— IRRITATION.  67 

This  will  show  you  Avhat  jaart  the  questions  to-day  under  con- 
sideration, which  you  might  regard  as  a  superfluous  exercise  of  the 
miiid  and  imagination,  have  played  at  various  times  ;  you  will  here- 
after learn,  from  the  history  of  medicine,  that  entire  systems  of 
medicine,  of  the  greatest  practical  importance,  are  based  on  hypoth- 
eses that  were  formed  for  the  explanation  of  this  symptom  in  the 
vessels,  of  this  irritability  and  of  irritability  of  the  tissues  generally. 

This  is  not  the  place  to  enter  into  a  thorough  historical  consid- 
eration of  this  question  ;  I  will  only  call  to  mind  a  few  hypotheses 
which  have  been  advanced  lately,  under  the  already-existing  knowl- 
edge of  the  vessels  and  parts  visible  to  the  naked  eye,  concerning 
the  occurrence  of  vascular  dilatation  from  irritation. 

[The  subject  has  become  more  comprehensible  since  Exner'^s  re- 
cent work  on  the  muscles  which  dilate  the  vessels,  showing  that 
there  may  be  active  dilatation  of  the  vessels  from  nervous  irrita- 
tion, and  that  it  is  accomplished  by  contraction  of  the  longitudinal 
fibres.  If  you  imagine  a  hollow  cylinder  whose  covering  is  of  lon- 
gitudinal muscular  elements,  and  s^lppose  these  elements  to  con- 
tract, of  course  their  transverse  diameter  increases,  and  there  will 
be  a  corresponding  increase  of  the  calibre  of  the  vessel  which  is 
made  up  of  these  elements.  Exner  has  proved  the  truth  of  this 
explanation  by  simple  experiment.  We  now  seem  certain  that  the 
circular  muscles  are  contractoi's,  the  longitudinal  dilators,  of  the 
vessels  ;  and  it  is  very  possible  that  one  set  may  be  induced  to  con- 
tract independently,  and  that  thus  there  may  be  an  active  dilatation. 
The  opinion  that  the  walls  of  the  vessels,  like  the  heart,  are  partly 
influenced  by  sympathetic,  partly  by  cerebro-spinal  nerves — the 
former  inducing  contraction,  the  latter  regulating  this  contraction 
— seems  gaining  gi'ound.  Ii'ritation  of  the  sympathetic  filaments 
would  increase  the  contraction  of  the  vessels,  their  division  would 
cause  paralysis  of  the  circular  muscles  ;  such  dilatation  might  also 
be  induced  by  irritation  of  the  cerebro-spinal  nerves. 

Having  reached  a  point  where  you  can  regard  dilatation  of  the 
vessels  as  an  active  reaction  of  the  muscles  of  the  vessels  to  nei'vous 
irritation,  you  will  ask  me  whether  experiment  shows  that  the  effect 
of  the  irritation  can  be  actually  observed  in  the  living  subject.] 

Observers,  who  have  of  late  persistently  studied  these  questions, 
refer  the  continued  capillary  dilatation  in  acute  inflammation  to 
changes  in  the  capillary  walls,  which  are  caused  directly  by  the 
inflammation.  Cohnheim  claims  that  inflammation  affects  the  walls 
of  the  vessels  peculiarly,  so  that  they  are  not  only  distended  by  the 
blood,  but  also  become  softer,  of  which  more  hereafter.  Samuel 
ascribes  inflammation  to  changes  m  the  relations  of  the  blood,  walls 


58  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

of  the  vessels,  and  tissue,  to  each  other.  Up  to  the  present  we  have 
not  succeeded  in  finding  accurately  the  chemical  and  physical 
changes  in  the  walls  of  the  vessels,  which  are  known  only  by  their 
results.  This  view  is  an  advance  beyond  Lotze's  view  (according 
to  which  the  molecules  of  the  capillary  walls  separated  from  nervous 
irritation),  inasmuch  as  no  nerve-action  seems  to  occur  in  this  capil- 
lary dilatation  developing  in  acute  inflammation.  This  also  corre- 
sponds with  the  demonstrations  of  Schlff,  already  mentioned,  that 
the  vascular  dilatations  forming  after  division  of  the  sympathetic 
are  not  inflammatory,  nor  do  they  lead  to  inflammation  without 
some  further  cause. 

It  is  well  known  that,  with  the  microscope,  we  can  follow  the 
circulation  in  the  smaller  arteries  and  veins,  as  well  as  in  the  capil- 
laries of  the  web  of  the  foot,  in  the  mesentery  and  tongue  of  the 
frog,  or  in  the  wing  of  a  bat ;  but  the  immediate  effect  of  a  mild 
chemical  or  mechanical  irritant  does  not  at  once  show  in  the  capil- 
laries, but  first  in  contraction  of  the  smaller  arteries,  occasionally 
also  of  the  veins  ;  this  is  very  evanescent,  of  scarcely  a  second's 
duration,  indeed,  it  often  escapes  observation,  and  we  then  suppose 
that  its  duration  and  grade  are  too  slight  for  us  to  measure.  This 
biief  contraction  is  followed  by  the  dilatation,  whose  immediate 
cause  is  indistinct  even  on  microscopical  observation.  We  shall 
soon  see  that  the  fluxion  is  the  result  of  paralysis  of  the  vessels. 

Yirchow  appears  to  think  that  the  irritation,  which  is  certainly  the 
immediate  cause  of  the  contraction,  is  followed  by  quick  fatigue  of 
the  muscles  of  the  vessels ;  that  after  a  tetanic  contraction  there  is  a 
relaxation,  just  as  in  irritated  nerves  and  muscles — a  view  which 
may  find  some  support  in  a  communication  from  Dubois-Eeymond 
about  the  painful  tetanus  of  the  muscles  of  the  vessels  in  the  head  as 
a  cause  of  headache  on  one  side,  so-called  hemicrania,  since  this  sup- 
posed tetanus  of  the  muscles  of  the  vessels,  induced  by  strong  excite- 
ment of  the  cer\4cal  portion  of  the  sympathetic,  was  certainly  followed 
by  their  relaxation  and  great  distention  of  the  vessels,  and  shortly  by 
symptoms  of  cerebral  congestion. 

But,  in  this  view  (by  which  a  relaxation  or  temporary  paralysis  of 
the  walls  of  the  vessels  and  a  consequent  decrease  of  their  resistance 
to  the  pressure  of  the  blood  would,  it  is  true,  be  explained  as  a  se- 
quent of  their  contraction),  we  must  not  forget  that  it  is  by  no  means 
proved  that  the  muscles  of  the  vessels,  once  irritated  and  excited  to 
rapid  contraction,  are  indeed  paralyzed,  while  in  other  muscles  this 
fatigue  usually  occurs  only  after  repeated  ii-ritation.  It  is  necessary 
arbitrarily  to  assume  that  the  muscles  of  the  vessels  very  readily  be- 
come fatigued,  which  is  directly  refuted  bv  experiment.     From  physi- 


SIMPLE  INCISED   WOUNDS   OF   THE   SOFT   PARTS.  59 

ology  you  know  tliat  Claude  Sernard  has  proved  that  the  contrac- 
tions and  dilatations  of  the  arteries  of  the  head  are  under  the  influ- 
ence of  the  cervical  portion  of  the  sympathetic  nerve,  as  I  have  al- 
ready indicated.  If  we  irritate  the  upper  cervical  ganglion  of  this 
nerve,  the  arteries  contract ;  if  we  divide  the  nerve,  there  is  dilatation 
(paralysis)  of  the  arteries  and  capillaries.  This  experiment  of  irri- 
tating the  muscles  of  tne  vessels  may  be  often  repeated,  without  their 
becoming  quickly  fatigued,  unless  the  electrical  current  be  too  strong ; 
hence  we  might  imagine  that  there  is  little  probability  in  the  hypoth- 
esis of  immediate  fatigue  after  a  single  irritation.  Schiff,  however, 
like  Lotze,  assumes  that  active  dilatation  of  the  vessels  is  possible  ;  he 
thinks  that  this  necessarily  follows  from  certain  experiments  ;  but 
this  is  perfectly  incomprehensible  to  me,  for  there  are  no  muscles  that 
could  actively  dilate  the  vessels. 

If  the  veins  alone  contracted  on  being  irritated,  filling  of  the  cap- 
illaries would  doubtless  follow  the  obstruction,  and  there  would  then 
be  no  difference  between  venous  (passive)  hjpertEmia  and  fluxion. 
But  this  supposition  is  quite  untenable ;  it  is  perfectly  incomprehensi- 
ble that  the  veins  alone  should  contract  on  inflammatory  irritation. 
That  the  veins  contract  on  mechanical  irritation,  you  may  see  in  the 
femoral  vein  of  an  amputated  thigh,  to  which  Virchow  has  called 
particular  attention,  and  this  irritability  lasts  even  longer  in  the  walls 
of  the  vein  than  in  the  nerves. 

Ilenle  already  advanced  the  view  that  the  symptom  of  distention 
of  the  vessels  from  irritation  was  directly  caused  by  paralysis  of  their 
walls ;  when  Lotze,  in  opposition  to  this,  says  that  it  is  not  supposable 
that  there  should  be  paralysis  of  the  muscles  in  a  man  who  is  exces- 
sively irritated  and  has  his  muscles  tense  and  his  face  glowing,  his 
objection  is  not  perfectly  tenable.  Nor  does  the  other  objection  of 
the  usually  acute  Lotze  appear  to  me  correct  when  he  says,  "  What 
shall  we  think  of  paleness,  of  the  contraction  of  the  vessels  that  results 
from  fright  and  terror  ?  Does  that  look  as  if  due  to  great  muscular 
action,  if  redness  in  anger  and  shame  is  induced  by  paralysis  ?  "  I  say 
this  proves  nothing.  Fright  may  throw  the  muscles  into  a  tetanic 
state,  which  is  usually  quickly  followed  by  fatigue  of  the  muscles  of 
the  vessels ;  immediately  after  a  great  fright,  we  generally  feel  the 
blood  pour  into  the  cheeks,  as  soon  as  we  begin  to  breathe  and  re- 
cover from  the  shock ;  we  soon  grow  red  again,  at  first  indeed  redder 
than  we  often  like ;  not  unfrequently  the  paling  from  fright  is  often 
overlooked,  and  only  the  succeeding  redness  perceived. 

Still,  apart  from  these  objections,  how  can  we  imagine  the  paralyz- 
ing action  of  an  irritated  nerve  ?  We  actually  know  such  phenomena 
from  physiology  ;  the  obstruction  of  the  heart's  action  bv  irritation  of 


60  UNION  OF  WOUNDS— IRRITATION. 

the  vagus  nerve,  of  the  movements  of  the  intestines  from  irritation  of 
the  splanchnic  nerve,  etc.  Here  a  vaso-motor  nerve-system  is  sui> 
posed  which  arrests  the  contraction  of  the  muscles ;  could  not  such  a 
vaso-motor  nerve-system  also  be  supposed  for  the  vessels — nerves, 
irritation  of  which  lessens  the  tone  of  thd  muscles  of  the  vessels  and 
thus  renders  the  walls  less  capable  of  resisting  the  pressure  of  blood  ? 
The  doctrine  about  vaso-motor  nerves  is  so  difficult  to  explain,  that 
even  a  brief  exposition  of  the  probable  possibilities  of  the  process 
would  lead  us  too  far ;  hence  I  must  content  myself  with  having  called 
attention  to  the  analogous  physiological  processes.  YircJioio  and 
Henle  agree  in  the  view  that  the  symptoms  of  fluxion  are  due  to 
paralysis  of  the  vessels,  althougb  they  refer  this  paralysis  to  differe?it 
causes ;  on  the  whole,  most  credence  is  attached  to  the  vicAV  that  the 
muscles  of  the  vessels,  like  those  of  the  heart,  are  partly  under  the 
influence  of  sympathetic,  partly  of  cerebro-spinal  nerves,  and  that  the 
former  cause  the  rhythmical  (automatic)  contractions  of  the  vessels,  and 
the  latter  act  as  regulators  or  obstructors  of  these  contractions.  Irri- 
tation of  the  sympathetic  filaments  would  increase  the  contractions 
of  the  vessels,  dividing  them  would  result  in  paralysis  of  the  mus- 
cles of  the  vessels  and  their  consequent  dilatation ;  but  the  latter 
might  also  be  caused  by  irritation  of  the  cerebro-spinal  obstructive 
nerves. 

The  discovery  by  Aebi/,  JSberth,  and  Auerhach^  that  the  blood- 
capillaries  are  entirely  composed  of  cells,  might  excite  new  hypotheses 
about  the  irritability  of  the  capillary  cells  and  their  influence  on  dila- 
tation and  contraction  of  the  capillaries,  although  even  this  would 
not  solve  the  mechanical  difficulty  which  opjDoses  the  idea  of  an  active 
vascular  dilatation.  In  the  action  of  local  irritation  and  entirely 
local  dilatation  of  the  vessels  we  have  the  choice  of  considering  that 
irritation  of  the  nerves  of  the  vessels  (or  of  the  living  cell-substance 
of  the  capillary  walls)  directly  disturbs  their  function,  or  that  this  dis- 
turbance is  due  to  reflex  irritation. 

You  have  now  material  enough  for  meditation.  None  of  the 
hypotheses  advanced  can  claim  to  fully  explain  the  symptoms  of 
fluxion,  although  some  of  them  perhaps  contain  the  germ  for  future 
perfect  development.  Still  the  recognition  of  this  truth,  the  dis- 
tinction of  hypotheses  from  observation,  is  useful ;  it  does  not  limit 
the  onward  progress  of  experiment,  but  constantly  reanimates  it. 
Congratulate  yourselves  that  it  is  permitted  to  you  and  the  coming 
generation  to  clear  up  this  point. 

We  shall  now  leave  this  question,  and  the  next  hour  shall  again 
return  to  the  field  of  certain  observation,  to  study  the  efifect  of  the 
wounding  on  the  tissue  itsel£ 


SIMPLE   INCISED  WOUNDS   OF   TOE   SOFT   PARTS.  61 


LECTURE   VI. 

(Jlianges  m  the  Tissue  during  Healing  by  the  First  Intention. — Plastic  Infiltration.— 
Inllammatory  New  Formation. — Eetrogrossion  to  the  Cicatrix. — Anatomical  Evi- 
dences of  Inflammation. — Conditions  under  which  Healing  by  First  Intention  does 
not  occur. — Union  of  Parts  that  have  been  completely  separated 

The  dilatation  of  the  capillaries  and  the  exudation  of  blood-serum 
that  usually  accompanies  it,  wliich  we  have  found  as  the  first  eflfect  of 
the  wound,  and  which  is  most  readily  seen  in  the  living  tissue,  as 
above  mentioned,  cannot  of  course  by  itself  cause  two  flaps  that  are 
brought  in  apposition  to  unite  organically — changes  must  take  place 
on  the  surfaces  of  the  wound,  by  which  the  latter  are  to  a  certain  ex- 
tent dissolved  and  melted  into  each  other.  For  a  long  time  union 
of  wounds  by  first  intention  was  represented  as  occurring  just  as 
you  render  two  ends  of  sealing-wax  soft  by  heat  to  fasten  them 
together  ;  so  here  the  substance  itself  was  supposed  to  become  the 
means  of  union.     The  union  is  really  moi-e  like  that  by  glue. 

Let  us  keep  in  mind  the  above  diagram  (Fig.  2),  and  suppose  that 
only  connective  tissue  and  vessels  have  been  w^ounded,  and  that  their 
reunion  is  the  question  for  consideration.  As  you  already  know,  con- 
nective tissue  consists  of  cellular  elements  and  filamentary  intercellular 
substance.  The  cellular  elements  are  partly  the  stable,  Jixed,  long- 
known  connective-tissue  corpuscles,  i.  e.,  flat,  nucleated  cells,  with  long 
processes,  which  adliere  to  the  connective-tissue  bundles,  partly  the 
wandering  cells  discovered  by  HecMinghausen,  which  are  identical 
with  white-blood  and  lymph  cells,  in  form,  species,  and  vital  peculiar- 
ities, are  probably  formed  for  the  most  part  in  the  lymphatic  glands, 
through  the  lymphatics  enter  the  blood,  from  the  capillaries  and  veins, 
occasionally  wander  into  the  surrounding  tissue  (as  discovered  by 
Strieker),  there  become  fixed  tissue-ce'ls,  or  again  (as  observed  by 
Hering)  enter  the  lymphatic  or  blood  vessels,  or  undergo  metamor- 
phoses not  yet  discovered. 

If  wc  examine  the  tissue  of  the  flaps  of  the  wound  a  few  hours 
after  the  injury,  we  shall  find  it  full  of  wandering  cells.  These  in- 
crease enormously  from  hour  to  hour ;  they  infiltrate  the  fibrous  tissue, 
already  softened  by  swelling,  and  even  wander  from  one  flap  of  the 
wound  to  the  other.  During  this  cell-activity,  and  probably  on  ac- 
count of  it,  the  connective-tissue  intercellular  substance  gradually 
changes  to  a  homogeneous  gelatinous  substance,  which  gradually  disap- 
pears as  the  cells  increase,  possibly  being  consumed  by  them  ;  so  that 
there  is  a  time  when  the  surfaces  of  the  wound  in  apposition  consist 


62 


PLASTIC   INFILTRATION. 


almost  entirely  of  cells,  held  together  by  a  very  shght  quantity  of 
gelatinous  intermediate  substance  (which  subsequently  becomes  firmer 
and  finally  fibrous). 

In  the  sketch  below  (Fig.  3),  a  sequel  to  the  above  diagram,  you 


Diagram  representing:  the  surface  of  tlie  wonnd  nnitcd  by  inflammatory  new  formation. 
«,  plastic  infiltration  of  tissue.    Magnified  30(M00. 


see  a  section  of  the  wound  now  united  by  newly-formed  tissue,  which 
once  for  all  we  shall  term  inflammatory  new  formation  or  primary 
cellular  tissue.  Virchow  calls  it  granulation  tissue,  Rindfleisch  germ- 
tissue.  The  inflammatory  new  formation  results  from  an  earlier  state 
in  which  the  still  filamentary  connective  tissue  is  infiltrated  with  innu- 
merable wandering  cells,  a  state  which  may  readily  return  to  the  nor- 
mal by  atrophy  of  these  cells.  This  stage  of  cellular  or  plastic  infiltror 
tion,  in  which  the  tissue  feels  firmer  than  in  watery  edematous  infiltra- 
tion, is  almost  always  at  some  distance  from  the  edge  of  the  wound, 
so  that  in  any  such  specimen  of  a  recent  wound  we  may  follow  the 
development  of  the  inflammatory  new  formation  from  the  plastic 
(cellular)  infiltration,  if  we  make  microscopical  examinations  from  the 


I 


SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 


63 


normal  tissue  toward  the  wound.  The  injury  represents  an  inflamma- 
torv  irritation,  whose  action  may  extend  somewhat  bevond  the  im- 
mediate vicinity  of  the  irritation,  but  then  rapidly  diminishes. 


Fig.  3  a. 


Vein  and  capillary  ves-sel  from  the  mesentery  of  a  fro"'.  which  has  lain  exposed  for  some  hours.  Red 
blood-cells  from  the  circul.itiou ;  white  blood-cells  lying  agamst  the  walls  and  wandering  into  the 
loose  connective  tissue  of  the  mesentery.     Magnified  about  SOO  diameters. 

In  the  great  majority  of  cases  there  will  be  at  least  a  slight  hwer 
of  coagulated  blood  between  the  flaps  of  the  wound  ;  this  also  extends 
somewhat  into  the  interstices  of  the  tissue  of  the  flaps  of  the  wound. 
This  blood-clot  may  sometimes  interfere  with  the  healing,  as  when, 
from  its  size  or  other  casues,  it  decomposes  or  turns  to  pus  ;  but  it  may 
also  become  cicatricial  tissue  and  perfectly  disappear  witji  the  new 
formation  in  the  flaps  of  the  wound ;  this  must  take  place  for  union 
by  the  first  intention  to  occur.  We  shall  hereafter  speak  of  the 
changes  that  take  place  in  the  clotted  blood  during  this  process. 

We  must  now  attend  to  the  question,  Whence  come  the  innumera- 
ble wandering  cells  that  infiltrate  all  inflamed  tissues  immediately  after 


64 


PLASTIC  INFILTRATION". 


their  irritation,  as  they  here  do  the  flaps  of  the  wound  ?  Of  late,  this 
question  has  received  the  following  wonderful  explanation,  which  ten 
vears  ao^o  would  have  been  considered  as  the  fancy  of  a  madman. 
Cohnheim  made  the  following  remarkable  observation :  he  introduced 
finely-powdered  anilin  blue  into  the  lymph-sac  in  the  back  of  a  frog, 
then  irritated  the  animal's  cornea  with  caustic,  and  found  that  numbers 
of  wandering  cells  (lymph-pus  cells)  containing  anilin  gradually  col- 
lected at  the  cauterized  point;  hence  the  conclusion,  at  an  irritated 
point  white  hlood-corpuscles  wander  from  the  vessels  into  the  tissue  ; 
these  white  hlood-corpuscles  cottstitute  the  inflammatory  cellular  in- 
filtration. Cohnheim  then  confirmed,  by  direct  observation  on  the 
mesentery  of  a  living  frog,  the  discovery  already  made  by  Strieker  on 
the  nictitating  membrane  that  had  just  been  removed,  that  under 
some  circumstances  the  white  blood-cells  wander  through  the  Avails 
of  the  vessels  into  the  tissues,  and  showed  also  that  this  occurred  to 
a  still  greater  extent  in  dilated  capillaries  and  veins. 

Although  it  was  afterward  shown  that  an  English  experimenter, 
Aug.  Waller,  had  several  years  previously  made  similar  observations 
on  the  mesentery  of  the  toad  and  the  frog's  tongue,  the  works  of 
the  German  observers,  Strieker,  Von  Recklinghausen,  and  Cohnheim, 
were  quite  independent  of  his,  and  Cohnheim  has  the  undivided 
honor  of  having  correctly  interpreted  his  observations  on  inflam- 
mation, which  have  constantly  advanced  to  the  present  time,  and 
of  having  presented  them  in  a  form  to  greatly  aifect  all  modern 
pathology. 

It  is  difficult  for  you,  gentlemen,  to  imagine  the  immense  impression 
made  on  all  histology  by  these  new  discoveries,  which  I  have  just 
imparted  to  you  as  simple  facts,  because  you  are  not  acquainted  with 
the  former  point  of  view  from  which  the  origin  of  inflammatory  new 
formations,  and  that  of  complicated  organized  growths,  was  regarded. 
From  previous  observation,  our  idea  of  the  affair  was  about  as  follows : 
It  was  supposed  that  the  cells  of  the  connective  tissue,  of  which  only 
one  variety,  the  fixed,  was  known,  increased  greatly  by  division  as  a 
result  of  irritation,  and  cellular  infiltration  thus  resulted.  Imagine 
yourselves  back  a  few  years,  in  a  time  when  nothing  was  known  of  the 
vital  peculiarities  of  young  cells,  of  their  amoeboid  and  locomotor  ac- 
tion, and  we  only  knew  how  to  deduce  the  course  of  the  pathological 
process  from  various  stages  of  the  diseased  but  not  dead  tissues,  as  is 
still  the  case  in  the  normally-developing  layer  ;  then  you  will  readily 
understand  that  it  was  decided  without  hesitation  that  the  cells  Ij'ing 
packed  together  in  the  inflamed  tissue  were  formed  out  of  one  an- 
other. Even  this  was  a  great  advance,  which  was  only  possible  after 
the  overthrow  of  the  generatio  wquivoca  ;  for,  not  long  before,  the 


SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS.  65 

development  of  cells  and  tissue  from  lymph,  coagulated  blood,  and 
fibrine,  was  firmly  believed  in.  The  first  observations  on  cell-division 
as  a  result  of  abnormal  irritation  were  made  on  cartilage  by  Redfern  in 
England  ;  then  followed  the  observations  of  Virchow  and  Heis  on  in- 
flamed cornea.  In  both  cases  it  was  seen  that  after  cauterization  with 
nitrate  of  silver,  or  after  introduction  of  a  seton,  the  tissue  was  filled 
with  young  cells ;  in  the  original  tissue-cells,  biscuit-shaped,  then 
double  nuclei  were  seen,  from  which  a  division  was  decided  on  ;  young 
cells  were  seen  grouped  together,  and  their  origin  from  the  tissue-cells 
seemed  indubitable.  Hence  arose  the  idea  that  inflammation  was  a 
process  in  the  tissues,  which,  entirely  independent  of  the  vessels,  was 
associated  with  a  rapid  luxuriant  proliferation  of  tissue-cells,  and  par- 
tial softening  and  disintegration  of  the  intercellular  tissue.  Vo7i 
JleGMinffhause>i's  discovery  ol  the  two  varieties  of  cells  found  in  con- 
nective tissue,  as  well  as  his  discovery  of  the  varied  movements  of 
pus-cells,  might  well  have  given  rise  to  the  question  wliether  the  pro- 
liferation of  the  cells,  on  irritating  the  tissue,  started  from  the  fixed 
or  movable  connective-tissue  corpuscles,  but  failed  to  do  so.  But 
now  observation  is  piled  on  observation  ;  and  we  are  driven  to  the 
supposition  that  all  young  cells  which  in  inflammation  we  find  ab- 
normally in  the  tissue  are  tcandering  white  hlood-cells. 

Observers  who  have  recently  investigated  this  point  do  not  all 
ao-ree ;  some  still  ascribe  to  the  stabile  cells  of  the  connective  tissue 
a  part  in  the  inflammatory  process.  StricJcer,  in  his  latest  publica- 
tions, maintains  that,  on  irritation,  the  stabile  tissue-cells  are  filled 
with  neoplasma,  increase  by  segmentation,  and  aid  in  the  formation 
of  pus  ;  but  he  does  not  deny  the  wandering  of  white  blood-cells. 
Cohnheim,  Key,  Eberth,  and  others  have  denied  the  correctness  of 
Stricker^s  observations,  or  rather  of  his  interpretations.  Observa- 
tions on  this  point  are  so  tedious  that  we  cannot  wonder  at  the  delay 
in  elucidating  a  question  apparently  so  simple. 

Of  course,  from  the  various  errors  to  which  we  are  liable  in  inter- 
preting the  significance  of  what  has  been  observed,  we  should  be  very 
careful  about  announcing  general  principles.  In  regard  to  the  in- 
flammatory changes  in  connective  tissue,  however,  as  far  as  my  obser- 
vation and  criticism  extend,  I  would  maintain  the  above  statements. 

In  cartilage  alone,  nothing  has  been  observed  difFefent  from  for- 
mer appearances.  As  the  hyaline  cartilage-substance  has  no  canals 
passable  for  cells,  so  far  as  we  at  present  know,  there  is  little  left 
except  to  suppose  that  the  increase  of  cells  in  the  cartilage-cavities 
after  irritation  results  from  division  of  the  protoplasm  of  the  cartilage- 
cells  ;  of  this  I  shall  hereafter  show  you  preparations  ;  still  hyaline 
cartilage  has  never  yet  been  watched  for  days  in  a  living  and  irri- 
6 


66  PLASTIC  INFILTRATIOX. 

tated  state,  and  consequently  this  observation  must  give  place  to 
the  studies  on  living  connective  tissue. 

But  in  hyaline  cartilage  there  is  no  such  acute  suppuration  or 
infiltration  of  pus  as  in  connective  tissue.  I  will  again  repeat  that  I 
only  consider  a  renovation  and  proliferation  of  connective  tissue  and 
corneal  cells  as  improbable  in  those  cases  where  the  protoplasm  has 
been  entirely  metamorphosed  even  to  the  nucleus,  that  is,  the  sta- 
bile connective  tissue  and  corneal  granules  of  grown  animals  whose 
tissues  resemble  those  of  man.  It  has  never  been  doubted  that  pro- 
toplasm, when  it  exists  as  such  in  cells,  that  is,  in  growing  tissues  of 
young  individuals,  may  increase  and  divide  up;  inattention  to  these 
points  may  have  given  rise  to  some  of  the  differences  in  the  views 
above  stated.  The  same  is  true  of  epithelial  tissues  ;  it  has  never 
been  maintained  that  the  cells  of  fully-developed  epithelial  tissue, 
the  elements  of  the  hair,  nails,  epidermis,  and  upper  layer  of  flat 
epithelium,  could  be  renovated  by  irritation,  while  it  in  not  denied 
that  constant  increase  of  the  young  elements  of  these  tissues  is  a 
physiological  necessity  for  their  growth  ;  here  the  only  difference  is 
that  growth  of  these  epithelial  tissues  continues  during  life,  while 
that  of  connective  tissues  only  goes  on  to  a  certain  age,  and  hence, 
after  cessation  of  the  growth,  wandering  cells  are  the  only  young 
elements  found  in  these  tissues. 

If  it  be  now  established  beyond  doubt  that  most  of  the  young 
cells  which  infiltrate  the  inflamed  tissue  and  sometimes  escape  from 
it  as  pus,  as  we  shall  hereafter  see,  are  white  blood-cells,  or  briefly 
icandering  cells,  then  two  questions  arise :  Why  do  so  many  cells 
wander  into  inflamed  tissue  ?  How  do  such  numbers  of  them  get 
into  the  blood,  and  whence  do  they  come?  There  are  different 
views  as  to  the  mode  of  escape  of  wandering  cells  through  the  walls 
of  vessels. 

My  views  are  as  follows :  The  first  change  that  we  see  in  inflamed 
tissues  during  life  is  dilatation  of  the  vessels  ;  the  immediate  result 
of  this  is  increased  transudation  and  a  collection  of  white  blood-cells 
along  the  periphery  of  the  vessel.  Then  the  wall  of  the  vessel  is 
gradually  softened  by  some  unexplained  chemical  process  that  goes 
on  in  every  inflammation,  so  that  by  their  active  movements  the 
white  blood-cells  gradually  enter  and  finally  pass  through  it.  Hence 
dilatation  of  the  vessels,  accumulation  of  white  cells  along  the  walls 
of  the  vessels,  and  softening  of  the  walls,  seem  to  me  to  be  the 
requirements  for  extensive  emigration  of  cells.  Cohnheim  and 
Samuel  have  lately  announced  the  same  opinion.  Whence  come  the 
immense  number  of  white  blood-cells  that  escape  in  inflammation  is 
entirely  a  physiological  question.     The  lymphatic  glands  and  the 


I 


SIMPLE  INCISED  WOUNDS  OF  THE   SOFT  PARTS.  67 

spleen  are  the  organs  which  we  first  suspect  ;  and,  although  it  can- 
not be  proved  that  numerous  new  lyinph-cells  are  formed  as  the 
others  escape,  it  is  very  probable,  especiallj^  as  we  know  from  clini- 
cal experience  that  the  lymphatic  glands  in  the  vi«jinity  of  an  inflam- 
mation almost  always  swell.  In  spite  of  careful  search,  I  have  been 
unable  to  discover  any  thing  about  the  morphological  process  of  this 
cell-formation,  but  consider  it  very  probable  that  lymph-cells  origi- 
nate from  sprouting  of  the  nets  of  the  IjMnph-sinuses  in  the  glands. 

I  must  mention  one  other  point,  which  is,  that  in  inflammation  red 
blood-corpuscles  also  not  unfrequently  pass  through  the  walls  of  the 
vessels  ;  according  to  Cohnhelm's  experiments,  this  is  greatly  influ- 
enced by  the  increased  intravascular  pressure. 

According  to  Arnold,  not  only  red  but  white  blood-cells  escape 
from  the  walls  of  the  vessels  at  points  where  the  capillary  vessels 
leave  small  openings  (stigmata,  stomata)  ;  it  is  said  to  be  more  es- 
pecially the  cement  of  the  cells  of  the  capillary  vessels  that  swells  on 
inflaming,  and  becomes  so  yielding  that  fine  streams  of  blood-serum 
flow  through  these  vessels  into  the  interstices  of  the  tissues. 

Let  us  now  return  to  our  wound,  and  see  what  becomes  of  the  tis- 
sue infiltrated  with  cells,  of  the  inflammatory  new  formation ;  how  the 
cicatrix  develops  from  it  while  the  cell-infiltration  extends  slowly  and 
sluggishly  at  some  distance  from  the  wound.  The  cells  in  the  surfaces 
of  the  wound,  which  already  adhere  loosely,  gradually  assume  a  spin- 
dle shape ;  the  intercellular  tissue  then  becomes  firmer,  the  spindle- 
cells  change  to  fixed  connective-tissue  cells,  and  finally  the  young 
cicatricial  tissue  assumes  more  and  more  the  form  of  normal,  fibrous 
connective  tissue  ;  that  is,  the  white  blood-cells  become  fixed  connec- 
tive-tissue cells,  as  probably  takes  place  even  in  the  embryo.  Here, 
again,  we  are  met  by  various  questions.  The  newly-formed  adhesive, 
interlacing  tissue  soon  becomes  firm,  especially  in  healing  by  the  first 
intention;  even  after  twenty-four  hours  we  find  its  intercellular  sub- 
stance quite  stiif  and  fibrinous,  and  the  borders  of  the  wound  are  also 
more  or  less  infiltrated  with  this  stiff"  substance  ;  it  is  only  the  early 
hardening  of  the  intercellular  connective  substance,  formed  of  trans- 
uded serum  and  softened  connective  tissue,  that  explains  why  the 
union  is  so  firm,  even  the  third  day,  that  the  flaps  of  the  wound  hold 
together  without  sutures,  for  without  such  connective  substance  the 
young  cellular  tissue  could  not  be  so  coherent.  This  stifl"ening  con- 
nective-tissue substance  (Fig.  8)  is  most  probably  fibrine,  which  con- 
sists of  the  transudation  coming  from  the  vessels  under  the  influence 
of  the  extravasated  blood-corpuscles,  possibly  also  of  the  wandering 
cells.  From  the  excellent  experiments  of  Alexander  Schmidt  it  is 
known  that  most  exudations  contain  the  so-called  fibrogenous  sub- 


68  HEALING  BY  FIRST  INTENTION. 

stance,  which  forms  fibrine  as  we  know  it  in  tlie  coagulated  state,  by- 
combining  with  the  fibro-plastic  substance  of  the  blood  and  other  tis- 
sues. Very  accurate  proportions  of  fibrogenous  and  fibrino-plastie 
substance  are  required  to  form  fibrine ;  these  favorable  requirements 
occur  in  many  inflammations.  Schmidt  considers  it  probable  that 
all  firm  fibrous  tissue  is  formed  and  maintained  by  the  tibrogenous 
substance  from  the  blood  being  precipitated  in  a  certain  manner 
around  the  tissue-cells,  because  they  contain  a  fibrino-plastie  sub- 
stance in  a  firm  shape.  Under  this  hypothesis  we  must  suppose  a 
specific  cell-action,  which  would  cause  the  coagulating  product  to  as- 
sume the  form  of  muscular  stri»  in  one  place  and  in  another  of  con- 
nective tissue.  In  our  case  this  is  a  very  probable  view,  for  we  see 
filamentary  connective  tissue  gradually  form  from  the  intercellular 
coagulated  fibrine.  It  is  true  the  amount  of  intercellular  substance 
in  the  new  formation  is  not  great,  but  there  is  little  doubt  that  the 
small  spaces  between  the  cells  are  filled  by  it.  A  short  time  subse- 
quently the  young  cicatricial  tissue  appears  still  to  consist  chiefly  of 
spindle-cells  closely  pressed  together  (Fig.  9) ;  but  then  the  spiudle- 
cells  diminish  greatly  by  flattening,  many  are  even  destroyed,  and  we 
have  now  a  filamentary  connective-tissue  substance,  which  is  to  be 
considered  partly  as  a  product  of  secretion,  partly  as  metamorphosed 
protoplasm  of  the  spindle-cells  ;  the  cicatricial  tissue  finally  remains 
stable  in  this  state.  Thiersch,  who  quite  recently  has  again  carefully 
studied  the  healing  of  wounds,  maintains  that  the  apparently  fibri- 
nous intermediate  substance  is  not  fibrine,  but  only  metamorphosed 
connective  tissue. 

I  will  not  deny  that  there  may  be  an  immediate  union  of  the  soft- 
ened edges  of  the  wound,  although  it  must  be  very  rare.  Quite 
recently  I  had  Dr.  Gussenbauer  make  a  new  series  of  accurate  obser- 
vations on  healing  by  the  first  intention  with  especial  reference  to 
Thiersch's  views.  He  could  not  confirm  the  latter's  observations,  but 
he,  as  well  as  Gilterhock,  arrived  at  results  which  in  the  main  corre- 
spond with  the  above  views,  which  I  arrived  at  from  my  own  studies. 

[Investigations  of  F.  Fuchs  render  it  probable  that  in  the  cornea, 
within  a  few  hours  after  cauterization,  there  is  active  wandering  of 
colorless  blood-cells,  w^hile  later  the  corneal  corpuscles  proliferate 
and  bring  about  detachment  of  the  slough  as  well  as  replace  the 
destroyed  tissue. 

Felix  V.  Winiioarter  has  shown  that  normally  the  spaces  between 
the  cells  of  the  capillary  walls  are  permeable  to  injections  under 
the  ordinary  pressure  of  the  heart's  action,  consequently,  for  the 
blood-plasma  ;  but  that  into  inflamed  tissue  the  injection  passes  in 
much  greater  quantity  and  at  more  places  under  the  same  pressuie. 


HEALING  BY  FIRST  INTENTION.  69 

The  cellular  new  formation  is  probably  composed  of  the  wan- 
dering cells  and  the  tissue-cells  which  are  capable  of  proliferation. 
It  has  long  been  known  that  cells  whose  protoplasm  has  all  been 
changed  and  which  no  longer  show  any  vital  changes  will,  under 
certain  irritations,  rejuvenate  and  act  as  embryonal  cells  rich  in 
protoplasm.  But  experiments  of  Ziegler  and  Tillman  show  that 
the  inflammatory  new  formation  may  develop  from  wandering  cells 
alone.  Ziegler  cemented  two  covering  glasses  in  such  a  way  as  to 
leave  a  space  between  them  into  which  fluid  and  wandei'ing  cells 
could  enter ;  these  he  placed  in  the  abdomen  of  living  animals, 
leaving  them  there  for  a  month.  Then,  after  treating  with  osmic 
acid  they  were  placed  under  the  microscope,  and  wandering  cells 
found  between  the  glasses  developed  to  a  cellular  tissue.  To  com- 
pletely exclude  the  pi'oliferation  of  normal  tissue-cells,  Tillman 
placed  sections  of  tissue,  hardened  in  alcohol,  with  incisions  as  in  a 
wound,  in  the  abdomens  of  living  animals,  and  the  incision  became 
entirely  closed  by  w^andering  colls,  vessels  were  formed,  and  the 
wandering  cells  transformed  to  connective  tissue. 


To  recapitulate  what  we  have  gone  over,  in  the  healing  of 
wounds  by  first  intention,  we  may  distinguish  three  grades  :  1, 
Union  by  an  organic  cement,  coagulated  plasma  ;  2.  Provisional 
union  by  a  cellular  neoplasia  ;  and,  lastly,  3,  Cicatrization  by  fila- 
mentary connective  tissue. 

The  healing  process  is  the  same  in  all  organs — in  the  cornea,  skin, 
muscles,  nerves,  even  in  cartilage  and  bones  ;  of  course,  there  is 
some  variation  dependent  on  the  tissue.  An  immediate  union  of 
the  divided  parts,  as  pictured  by  some  surgeons,  has  not  been  shown 
by  accurate  examination  ;  wounds  made  experimentally  in  the  coi'- 
nea  with  the  sharpest  knife  always  show  an  inter-substance,  which 
may,  it  is  true,  be  microscopic,  but  is  a  scar  in  the  strict  sense  of 
the  word.  Hence  it  is  theoretically  incorrect  to  term  healing  by 
first  intention  as  a  complete  restitutio  ad  integrum.'] 

Meantime,  what  has  become  of  the  closed  ends  of  the  vessels  ? 
The  blood-clot  in  them  is  reabsorbed  or  organized  ;  the  walls  of  the 
vessels  send  out  shoots  which  communicate  with  the  vascular  loops  of 
the  opposing  border  of  the  wound,  and  with  each  other.  In  this  way, 
however,  only  the  rather  scanty  union  of  the  opposing  vascular  loops, 
which  is  at  first  slight,  is  accomplished ;  these  were  already  formed  by 
extensive  tortuosities  and  windings  of  the  vessels,  which  had  loop- 
shaped  terminations  after  the  injury  (Figs.  12-14).  This  is  not  the 
place  to  go  into  the  details  of  this  interesting  development  of  the  vas- 
cular loops;  their  development  is  not  due  solely  to  dilatation,  but  very 


70 


SIMPLE   INCISED   WOUNDS   OF   THE   SOFT  PARTS. 


Fig.  3  b. 


The  course  of  the  formation  of  tliese  vessels  runs 
fl.  b.  c.  These  ehansres  occurred  in  10  hours, 
Magnified  300.    After  Arnold. 


much  to  interstitial  growth  of 
the  walls  of  the  vessels.  The 
oi'iginal,  formerly-existing  vascu- 
lar union  is  thus  replaced  by  a 
newly-formed  vascular  net-work 
which  is  at  first  far  richer. 

Quite  recently  Arnold  has 
most  carefully  studied  the  pro- 
cess of  the  development  of  ves- 
sels, and  has  seen  it  go  on  in  the 
tails  of  tadpoles  (Fig.  3  b.) 

Although  the  heart  and  larger 
vessels  of  the  embryo  seem  to 
originate  from  appointed  cell- 
groups  of  the  middle  germinal 
layer,  by  the  peripheral  parts 
forming  the  wall  of  the  vessel 
and  the  central  parts  tlie  blood- 
cells,  later  this  does  not  seem  to 
occur ;  at  least,  observations  made 
on  this  point  by  HoTcltansJvij  and 
others  do  not  seem  to  have  ob- 
tained much  credence.  According 
to  Arnold''s  investigations,  off- 
shoots from  the  vessels  seem  to 
be  the  only  mode  of  development 
of  vessels  in  the  embr3'o. 

I  formerly  thought  that  there 
must  be  another  mode  of  growth 
for  vessels  in  the  formation  of 
granulations  and  in  some  neo- 
plasia, namely,  a  tubular  forma- 
tion by  laying  together  spindle- 
cells,  as  at  o,  J,  and  c,  in  Fig. 
3  c  ;  this  I  called  "  secondary  " 
formation  of  vessels  ("  primary  " 
I  applied  to  the  development  of 
the  heart  and  larger  vessels  in 
the  middle  germ-layer).  The 
development  of  vessels  by  off- 
shoots I  called  "  tertiary."  But, 
since  recent  investigations,  I 
readily  agree  that  the  mode  I 
termed  "  secondary  "  possibly  did 


HEALING   BY  FIRST   INTENTION. 


71 


not  exist,  and  that  the  fine  plasma  string  (the  offshoot)  and  the  fine  tube, 
on  which  the  spindle-cells  growing  out  of  the  young  adventitia  lay, 
may  have  escaped  my  notice.  But  I  will  not  neglect  to  mention  that 
Thiersch^  supported  by  recent  observations,  has  repeated  his  former 
assertions  (which  then  seemed  to  me  improbable)  that  in  the  j^oung 
inflammatory  neoplasia  there  is  a  net-work  of  tubes,  connected  with 
the  blood-vessels  by  stigmata,  which  is  bounded  merely  by  the  tissue- 
cells,  not  by  special  walls  ;  this  agrees  very  well  w^ith  the  recent  ob- 
servations on  capillaries  in  inflamed  tissues.  According  to  this,  there 
would  be  blood-vessels  in  this  tissue  which  are  not  circular  canals, 
but  irregular  intercellular  passages,  perhaps  merely  bounded  by  spin- 
dle-cells. 


Fia.  3  0. 


Disposition  of  vessels  in  the  vitreous  body  of  an  embryo  calf.     Magnified  about  600.     After  Arnold. 

As  a  result  of  the  restoration  of  circulation  through  the  young  cica- 
trix, the  circulatory  disturbances  caused  by  the  injury  are  removed, 
the  redness  and  swelling  of  the  borders  of  the  wound  disappear  ;  from 
the  numerous  vessels,  the  cicatrix  appears  as  a  fine  red  stripe.    Now 


72  SIMPLE   INCISED   WOUNDS   OF  THE   SOFT   PARTS. 

the  consolidation  of  the  cical  rix  must  take  place  :  this  is  accomplished, 
on  the  one  hand,  by  the  partial  disappearance  of  the  newly-formed 
vessels,  whose  walls  fall  together,  and  they  thus  become  solid,  fine, 
connective-tissue  strings  ;  on  the  other  hand,  by  the  intercellular  sub- 
stance becoming  firmer  and  containing  less  water,  as  above  mentioned, 
the  cells  assume  the  flat  form  of  connective-tissue  corpuscles,  or  disap- 
pear ;  possibly  some  of  them  remain  as  wandering  cells,  and  return 
again  into  the  lymphatics  or  blood-vessels.  To  this  condensation  and 
atrophy  is  due  the  great  contractile  power  of  the  cicatricial  tissue, 
bv  means  of  which  large,  broad  cicatrices  may  occasionally  be  reduced 
to  half  their  original  size. 

At  the  first  glance,  it  might  appear  to  you  contradictory,  that  an 
apparently  excessive  capillary  net-work  should  be  formed  in  the  young 
cicatrix,  and  should  subsequently  be  for  the  most  part  obliterated.  We 
cannot  explain  this  apparent  excess,  still  there  are  plenty  of  analogies 
in  embryonal  development ;  I  only  need  to  remind  you  that  there  is  a 
period  in  foetal  development  when,  even  in  the  vitreous  body,  there  is 
a  capillary  net-work,  which,  as  you  know,  disappears,  leaving  scarcely 
a  trace. 

Not  to  fatigue  you  with  so-called  theoretical  subjects,  I  leave  this 
field  for  a  short  time,  and,  before  leaving  healing  by  the  first  inten- 
tion, as  a  point  fully  understood,  I  shall  make  a  few  remarks  on  the 
causes  that  may  prevent  this  mode  of  healing,  even  when  the  flaps  of 
the  wound  are  in  apposition. 

Healing  by  first  intention  does  not  take  place  :  1.  When  the  edges 
of  the  wound  are  brought  together  by  plasters,  or  sutures,  but  their 
tension  or  tendency  to  separate  again  is  very  great.  Under  these 
circumstances,  either  the  plasters  do  not  keep  the  wound  accurately 
closed,  or  the  sutures  cut  through  the  flaps ;  perhaps  also  the  tension 
of  the  tissues  obstructs  the  flow  of  blood  in  the  capillaries,  and  thus 
disturbs  the  cell  development  and  formation.  How  great  this  tension 
must  be,  and  what  means  we  have  for  relieving  it,  you  can  only  learn 
in  the  clinic. 

2.  A  further  obstruction  to  healing  is,  a  large  amount  of  blood 
poured  out  between  the  edges  of  the  wound  ;  this  interferes  with  the 
process  of  healing,  partly  as  a  foreign  body,  and  partly,  if  it  decom- 
poses, by  the  influence  of  the  process  of  decomposition. 

3.  Other  foreign  bodies,  as  sand,  dirt,  alkaline  urine,  faeces,  etc., 
also  retard  the  healing,  partly  mechanically,  partly  chemically.  Hence 
these  substances  should  be  carefully  removed  before  uniting  the  wound. 
In  wounds  of  the  urinary  bladder,  it  is  not  usual  to  attempt  the  clos- 
ure of  the  skin-wound ;  the  urine  would  force  its  way  into  the  sub- 
cutaneous cellular  tissue,  or  into  the  peritoneal  sac,  and  excite  terrible 


HEALIXG   BY   FIRST   INTENTIOX.  73 

injury.  Here,  under  some  circumstances,  it  would  be  a  decided  fault 
to  unite  the  wound,  although  of  late  the  views  on  this  particular  point 
differ  somewhat  from  those  of  former  days. 

4.  Lastly,  from  a  contusion,  whose  effect  on  the  flaps  of  the  wound 
we  may  fail  to  observe,  there  may  have  been  an  extensive  disturbance 
of  circulation  and  destruction  of  minute  tissue,  which  has  induced  the 
partial  death  of  certain  parts  or  of  the  whole  surface  of  the  wound. 
Then,  as  there  is  no  cell-formation  in  the  edges  of  the  wound,  but  only 
where  the  tissue  is  still  living,  we  have  small  tags  of  the  destroyed 
tissue  lying  as  foreign  bodies  between  the  edges  of  the  wound  ;  these 
must  prevent  healing  by  first  intention.  If  this  mortification  attack 
only  minute  particles,  these  may  possibly  quickly  undergo  molecular 
disintegration  and  absorption  ;  this  ma}^  occur  not  unfrequently.  We 
shall  speak  more  extensively  of  this  mortification  of  the  tissue,  and  of 
its  detachment  from  the  healthy  parts,  when  treating  of  contusions, 

ExjDerience,  arising  from  many  observations  in  judging  of  wounded 
surfaces,  will  hereafter  enable  you  in  most  cases  to  say  whether  heal 
ing  by  first  intention  may  be  expected  or  not,  and  j^ou  will  also  learn 
when  it  may  be  useful,  even  in  doubtful  cases,  to  try  to  aid  this  union 
by  applying  dressings. 

You  will  occasionally  hear  of  wonderful  cases  where  parts  of  the 
body,  completely  separated,  have  again  become  united.  This  appears 
to  be  actually  the  case.  I  have  never  had  the  opportunity  of  making 
any  observations  on  such  cases ;  still,  even  in  late  days,  very  trust- 
worthy men  have  asserted  that  they  have  seen  small  portions  of  skin 
again  unite  after  being  removed  from  the  fingers  by  a  blow  or  cut, 
then  carefully  replaced  and  fastened  on  with  adhesive  plaster.  For^ 
merly  I  contended  against  the  possibility  of  this  healing,  but  must  now 
admit  it,  also  on  theoretical  grounds,  after  it  has  become  imaginable 
that,  through  the  movements  of  the  cells,  the  detached  portions,  if  not 
too  great,  may  soon  be  restored  to  life  again  by  the  entrance  of  wan- 
dering cells.  That  we  may  successfully  transplant  a  twig,  cut  from  one 
tree,  into  another  one,  is  well  known  ;  but,  as  the  circidation  in  plants 
is  not  by  pumping,  but  the  sap  runs  simply  by  cellular  force,  the  anal- 
ogy is  not  very  close  ;  it  was  more  remarkable,  it  is  time,  that  a  cock's 
spurs  could  be  transplanted  to  his  comb,  but  between  birds  and  men 
the  differences  in  the  formative  process  are  also  very  great,  and  any 
immediate  transfer  of  observations  is  inadmissible  in  practice. 

When  treating  of  the  cicatrization  of  wounds  with  loss  of  sub- 
stance, we  shall  investigate  the  discovery  of  Meverdin  that  we  may 
cause  epidermis  to  grow  on  granulating  surfaces. 

[Before  the  formation  of  vessels,  blood-plasma  may  circulate  in 
the  tissue,  which  is  very  important  for  its  nutrition.     This  p/as- 


74  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

matic  circulation,  immediately  after  the  injury,  from  dilatation  of 
the  capillaries,  may  be  very  important  for  the  edges  of  the  wound 
itself,  their  vessels  having  been  thrombosed.  Even  normally,  to 
some  extent,  streams  of  blood-plasma  may  escape  through  the  walls 
of  vessels  and  spread  around  in  the  tissue. 

Portions  of  the  body  that  have  been  separated  may  directly  ad- 
here, when  reapplied,  if  the  conditions  are  good  for  this  plasmatic 
circulation.  The  divided  part  here  acts  as  young  cicatricial  tissue 
previous  to  its  vascularization  ;  it  must  first  be  nourished  if  organic 
union  is  to  result.  The  size  is  the  most  important  factor  ;  a  small 
piece  with  large  surface*  is  more  readily  saturated  with  plasma.  The 
structure  is  also  important ;  it  is  an  advantage  if  the  tissue  contains 
numerous  channels  for  the  plasmatic  circulation  ;  fatty  tissue  is  the 
most  unfavorable  for  this,  as  the  channels  are  occupied  by  fat-cells. 
When  the  separated  part  is  once  nourished  by  the  plasma,  the  union 
goes  on  well ;  white  blood-cells  Avander  into  the  divided  portion, 
and  the  whole  is  nourished  by  plasma  till  the  neoplastic  vessels  grow 
into  the  divided  pai't,  and  normal  circulation  is  restored. 

The  union  of  pieces  of  skin  to  granulating  surfaces  would  go  on 
in  much  the  same  way.  These  j^ieces  may  be  introduced  some 
hours  after  death  of  the  part  from  which  they  are  taken.  Dr,  E. 
P.  Brevier  {3IecUca,l  Record,  May,  1882)  has  made  some  experiments 
which  seem  to  place  thirty-six  hours  as  the  limit  of  this  time. 

A  common  instance  of  readherence  of  divided  parts  is  the  re- 
implantation of  teeth  that  have  been  pulled  by  mistake.] 

In  his  history  of  plastic  operations  Zeis  has  collected  all  pub- 
lished cases  of  reunion  of  parts  that  had  been  entirely  separated. 
Bosenherg  has  completed  this  list  to  the  present  time,  and  gives  a 
number  of  cases  carefully  observed  by  himself  where  portions  of 
noses  and  fingers  which  had  been  cut  off  reunited.  He  confirmed 
previous  observations  that  the  epidermis  and  occasionally  small  por- 
tions of  the  surface  of  such  parts  became  gangrenous,  while  healing 
went  on  below. 


SIMPLE    INCISED    WOUNDS    OF    THE    SOFT    PARTS.  75 


LECTURE    VII. 

Changes  perceptible  to  the  Naked  Eye  in  Wounds  with  Loss  of  Substance. — Finer  Pro- 
cesses in  Healing  with  Granulation  and  Suppuration. — Pus. — Cicatrization. — Ob- 
servations on  "Inflammation." — Demonstration  of  Preparations  illustrative  of  the 
Healing  of  Wounds. 

It  now  remains  for  us  to  inquire  what  becomes  of  the  wound,  if, 
under  the  above  circumstances,  it  does  not  heal  by  first  intention. 
Then,  as  the  flaps  gape,  we  have  an  open  wound  before  us  ;  and 
the  conditions  are  the  same  as  if  the  gaping  wound  had  not  been 
closed,  or  as  if  a  piece  had  been  cut  out,  as  in  a  wound  with  loss  of 
substance.  Accurate  observation  of  such  wounds,  which  are  usually 
covered  with  some  unirritating  body,  as  with  a  fold  of  linen  dipped  in 
oil,  with  oiled  or  dry  charpie,  etc.,  shows  the  following  changes — if  we 
examine  it  daily,  this  is  not  necessary  it  is  true,  and  may  even  be  in- 
jurious :  after  tv/entj'-four  hours,  you  find  the  borders  of  the  wound 
slightly  reddened,  somewhat  swollen,  and  sensitive  to  the  touch  ;  the 
same  symptoms  as  in  closed  wounds.  As  in  healing  by  first  inten- 
tion, these  sym.ptoms  may  be  very  insignificant  or  entirely  absent,  as 
in  old,  relaxed,  flabby  skin,  also  in  strong  skin  with  thick  epidermis. 
We  observe  these  symptoms  best  in  the  skin  of  healthy  children.  An 
extensive  and  increasing  redness,  swelling,  and  pain  about  the  wound, 
make  us  suspect  an  abnormal  course ;  just  as,  with  the  same  symptoms 
in  a  wound  healing  by  first  intention,  various  individual  circumstances 
are  to  be  considered,  and  the  vibrations  from  the  normal  to  the  abnor- 
mal are  so  numerous,  that  the  dividing  line  is  often  difficult  to  deter- 
mine. After  the  first  twenty-four  hours,  the  surface  of  the  wound  has 
changed  but  little  ;  all  over  it  you  can  still  recognize  the  tissues  quite 
^distinctly,  although  they  have  a  peculiar  gelatinous,  grayish  appear- 
ance ;  you  also  find  a  considerable  number  of  yellowish  or  grayish-red 
email  particles  over  the  surface ;  on  close  examination,  you  find  these 
to  be  small  fragments  of  dead  tissue,  which  still  adhere,  however.  The 
second  day,  you  may  already  notice  a  trace  of  reddish-yellow,  thin 
fluid  over  the  wound,  the  tissues  appear  more  regularly  grayish  red 
and  gelatinous,  and  their  boundaries  become  more  indistinct.  The 
third  day,  the  secretion  from  the  wound  is  pure  yellow,  somewhat 
thicker,  most  of  the  yellow  dead  particles  are  detached  and  flow  off 
with  the  secretion ;  the  surface  of  the  wound  becomes  more  even  and 
regularly  red — it  cleans  off,  as  we  say  technically.  If  you  had  not 
bound  up  the  wound  (a  stump  from  amputation,  for  instance),  and  had 
received  in  a  basin  the  secretion  that  formed,  the  first  and  second  day 
you  would  find  it  bloody,  brownish  red,  then  of  a  gelatinous  dirty  gray, 


yg  HEALING  BY  GRANULATIONS. 

then  dirty  yellow :  at  the  points  where  the  secretion  flows  from  the 
wound,  fibrine  not  unfrequently  stiflFens  in  drops.  If  you  examine  care- 
fully with  a  lens,  even  the  third  day,  you  will  see  numerous  red  nod 
ules,  scarcely  as  large  as  a  millet-seed,  projecting  from  the  tissue 
— small  granules,  granulations,  fleshy  warts.  By  the  fourth  or  sixth 
day  these  have  greatly  developed,  and  gradually  join  into  a  fine,  granu- 
lar bri"-ht-red  surface — the  granulating  surface  ;  at  the  same  time,  the 
fluid  flomng  from  this  surface  becomes  thicker,  pure  yellow,  and 
of  creamy  consistence  ;  this  fluid  is  jows,  and,  when  of  the  quality  here 
described,  it  is  good  pus,  pus  honum  et  laudahile  of  old  authors. 

Of  this  normal  course  there  are  many  varieties,  which  chiefly  de- 
pend on  the  parts  injured,  and  the  mode  of  injury ;  if  large  shreds  of 
tissue  from  the  surface  of  the  wound  die,  the  wound  is  longer  in  clean- 
ing ofi",  and  then  you  may  sometimes  see  the  white,  adherent  shreds  of 
dead  tissues  still  clinging  for  days  to  the  surface,  most  of  which  is  al- 
ready granulating.  Tendons  and  fasciae  are  particularly  apt  to  have 
their  circulation  so  impaired,  even  by  simple  incised  wounds,  that  they 
die  to  an  unexpected  extent  from  the  cut  surface,  while  there  is  little 
loss  of  loose  cellular  tissue  or  muscle.  This  is  undoubtedly  due  partly 
to  deficient  vascularity  of  the  tendinous  parts,  partly  to  their  firm- 
ness, which  does  not  permit  rapid  collateral  dilatation  of  the  vessels ;  the 
same  is  true  in  injuries  of  bone,  especially  of  the  cortical  substance, 
where  there  is  often  death  of  the  injured  bone-surface,  that  requires 
a  long  time  for  detachment.  Other  obstacles  to  active  development 
of  granulations  are  constitutional  conditions;  for  instance,  in  very 
old  or  debilitated  persons,  or  badly-noiu-ished  children,  the  develop- 
ment of  granulations  will  not  only  be  very  slow,  but  they  will  look  very 
pale  and  flabby.  Hereafter,  at  the  close  of  this  chapter,  I  -will  give 
you  a  short  review  of  those  anomalies  of  granulation  which  are  daily 
occurrences  in  large  wounds,  and,  to  a  certain  extent,  may  be  regarded 
as  normal  or  at  least  customary. 

But,  to  return  to  the  observation  of  the  normally- developing  layer 
of  granulations,  with  the  continued  secretion  of  pus,  you  perceive 
that  the  granulations  become  more  and  more  elevated,  and  sooner  or 
later  attain  the  level  of  the  skin,  and  not  unfrequently  rise  above  it. 
With  this  process  of  growth,  the  individual  granules  become  thicker, 
and  more  confluent,  so  that  they  can  hardly  be  recognized  as  separate 
nodules  ;  but  the  entire  surface  assumes  a  glassy,  gelatinous  appearance. 
Occasionally  the  granulations  remain  for  a  long  time  at  this  stage, 
so  that  we  have  to  use  various  remedies  to  restrain  the  proliferating 
neoplasm  within  bounds  that  are  requisite  for  recovery ;  on  the 
periphery,  particularly,  the  granulations  should  not  rise  above  the 
level  of  the  skin,  for  the  cicatrization  has  to  commence  at  this  point. 


SIMPLE   IXCISED   WOUNDS  OF   THE   SOFT   PARTS.  77 

The  following  metamorphoses  now  gradually  occur :  the  entire  surface 
contracts  more  and  more,  becomes  smaller ;  on  the  border,  between  skin 
and  granulations,  the  secretion  of  pus  diminishes ;  first,  a  dry,  red 
border,  about  half  a  line  broad,  forms  and  advances  toward  the  centre 
of  the  wound,  and,  as  it  progresses  and  traverses  the  granular  surface, 
it  is  followed  closely  by  a  bluish-white  border,  which  passes  into  nor- 
mal epidermis.  These  two  seams  result  from  the  development  of 
epideiinis,  which  advances  from  the  periphery  toward  the  centre ; 
cicatrization  begins ;  the  young  cicatricial  border  advances  half  a  line 
or  a  line  daily ;  finally,  it  covers  the  entire  granulation  surface.  The 
young  cicatrix  then  looks  quite  red,  and  is  thus  sharply  defined  from 
the  healthy  skin;  it  feels  firm,  more  so  than  the  cutis,  and  is  stiU 
very  intimately  connected  with  the  subjacent  parts.  In  the  course 
of  some  months,  it  gradually  grows  paler,  softer,  more  movable,  and 
finally  white  ;  in  the  course  of  months  and  years,  it  grows  still  smaller, 
but  often  remains  whiter  than  the  cutis  all  through  life.  The 
strong  contraction  in  the  cicatrix  often  causes  traction  on  the  neigh- 
boring parts,  an  effect  that  is  occasionally  desirable,  but  sometimes 
very  unwelcome,  as,  for  instance,  when  such  a  cicatrix  on  the  cheek 
draws  the  lower  eyelid  down,  causing  ectropion. 

You  Avill  occasionally  see  it  asserted  that  the  cicatrization  of  a 
granulating  surface  may  sometimes  begin  from  several  patches  of 
epidermis  forming  in  its  midst.  This  is  onl}^  true  of  cases  where  por- 
tions of  cutis  with  rete  Malpighii  have  remained  in  the  midst  of  the 
woimd,  as  may  readily  happen  in  gangrenous  wounds,  as  the  caustic 
agent  may  penetrate  unequally  deep.  Under  such  circumstances,  epi- 
dermis again  forms  fi-om  some  remainmg  portion  of  the  papillary 
layer,  that  has  the  slightest  possible  covering  of  cells  of  the  rete  Mal- 
pighii ;  at  these  points  we  have  the  same  circumstances  as  when  we 
have  raised  a  vesicle  on  the  skin  by  cantharides,  inducing  by  the  rapid 
exudation  an  elevation  of  the  epidermis  from  the  mucous  layer  of 
the  skin  ;  this  is  followed  by  no  granulations,  if  you  do  not  continue 
to  irritate  the  surface,  but  horny  epidermis  again  forms  at  once  over 
the  mucous  layer.  But,  if  there  be  no  such  remnant  of  rete  Malpighii, 
we  never  have  these  islands  in  the  cicatrix,  the  formation  of  epidermis 
only  takes  place  gradually,  from  the  periphery  of  the  wound  toward 
the  centre.  I  believe  this  so  firmly,  that  I  think  surgeons,  who  say  they 
have  seen  otherwise,  must  be  mistaken  in  some  way. 

The  transplantation  of  epidennis  after  Meverdiii's  method  also  ap- 
pears to  me  to  favor  the  view  that  epithelium  is  only  developed  from 
epithelium. 

After  having  considered  the  external  conditions  of  the  wound,  the 
development  of  granulations,  of  pus,  and  of  the  cicatrix,  we  must 


78 


DILATATION  OF  THE  VESSELS. 


now  turn  again  to  tlie  more  minute  changes  by  which  these  external 
symptoms  are  induced. 

It  will  be  simplest  for  us.  again,  to  represent  a  relatively  simple 
capillary  net-work  in  the  connective  tissue :  suppose  a  crescentic  piece 
to  be  cut  out  of  it  from  above ;  first,  there  will  be  bleeding  from  the  ves- 
sels which  will  be  arrested  by  the  formation  of  clots  as  far  as  the 
next  branches.  Tlien,  there  must  be  dilatation  of  the  vessels  about 
the  wound,  which  is  due  partly  to  fluxion,  partly  to  increased  press- 
ure ;  an  increased  transudation  of  blood  serum,  or  an  exudation,  is 
also  a  necessary  result  of  the  capillary  dilatation,  from  causes  above 
given ;  the  transuded  serum  contains  some  fibrogenous  substance, 
which,  by  the  influence  of  the  newly-formed  cells  in  the  most  super- 
ficial layers,  coagulates  to  fibrine,  while  the  serum,  mixed  with  blood 
plasma,  flows  ofi".  The  vascular  net-work  would  assume  the  following 
sliape : 


Fie.  4. 


Diagram  of  a  wound,  -with  loss  of  substence.    Vaecular  dilatation,  magnified  300^00  times. 


In  most  cases,  from  insufficient  supply  of  blood-plasm  at  the  sur- 
face of  the  wound,  more  or  less  particles  of  tissue  will  die ;  as  the 
stoppage  of  vessels  must,  of  course,  deeply  afi'ect  the  nutrition  of  tis- 
sues not  very  vasciilar,  and,  where  the  tissues  are  very  stifi",  dilatation 


SIMPLE  INCISED   WOUNDS  OF  THE   SOFT  PARTS.  79 

of  the  vessels  will  be  interfered  with.  Let  us  suppose  that  the  upper 
layer,  shaded  in  the  diagram,  is  dead  from  the  changes  in  the  circula- 
tion. "What  will  now  take  place  in  the  tissue  itself?  Essentially, 
the  same  changes  as  in  the  united  edges  of  a  wound ;  wandering 
of  white-blood  cells  through  the  walls  of  the  vessels,  their  collection 
in  the  tissue  with  the  secondary  action  they  induce ;  plastic  infiltra- 
tion, and  inflammatory  new  formation.  But,  since  there  is  no  oppos- 
ing wounded  surface,  with  which  the  new  tissue  can  coalesce,  then  to 
be  quickly  transformed  to  connective  tissue,  the  cells,  escaping  from 
the  vessels,  remain  at  first  on  the  surface  of  the  wovmd ;  the  exuded 
fibrinous  material  on  the  surface  of  the  wound  becomes  soft  and 
gelatinous ;  at  the  same  time,  the  infiltrated  tissue  of  the  surface  of 
the  wound  assumes  the  same  peculiarities ;  the  soft  connective  tissue, 
into  %vhich  the  young  vessels  shortly  grow,  even  if  only  present  in 
small  quantities,  holds  together  the  cells  of  the  inflammatory  new  for- 
mation, which  constantly  increase  in  number.  The  granulation  tissue 
is  thus  formed ;  this  is,  therefore,  a  highly-vascular  inflammatory  new 
formation.  At  first,  it  grows  constantly,  the  direction  of  its  growth 
is  from  the  bottom  of  the  wound  toward  the  surface ;  the  tissue  is, 
however,  of  different  consistence  in  the  various  layers,  its  superficial 
surface  especially  is  soft,  and  most  superficially  of  fluid  consistence, 
for  here  the  intercellular  substance  becomes  not  only  gelatinous,  but 
fluid ;  this  uppermost  thin  fluid  layer,  which  is  constantly  flowing 
and  being  constantly  renewed  from  the  granulation  tissue  by  cell-exu- 
dation, is  pus  (Fig.  6). 

Hence,  pus  is  fluid,  as  it  were  melted,  dissolved  inflammatory  new 
formation.  Where  pus  is  present  in  quantity  it  must  have  come  from 
some  sort  of  granulation  tissue  or  from  some  other  highly-vascular 
and  usually  highly -cellular  source ;  this  source  need  not  always  be  a 
surface,  as  in  the  present  case,  but  may  lie  deep  in  the  tissue  and  form 
a  cavity ;  the  centre  of  an  inflammatory  new  formation  anywhere  in 
the  tissue  may  break  down  into  pus ;  then  we  have  an  abscess. 

We  shall  frequently  have  occasion  to  speak  of  this  relation  of  pus 
and  granulations  to  each  other  ;  hold  fast  to  the  idea  of  granulations 
being  tissue  (not  granules),  and  of  pus  being  fluid  inflammatory  new 
formation,  and  you  will  hereafter  readily  understand  many  processes, 
especially  chronic  inflammations,  whose  variable  appearance  you  would 
otherv/ise  find  incomprehensible. 

Let  us  now  say  a  few  words  about  pus  itself.  If  left  standing  in 
a  vessel,  it  separates  into  an  upper,  thin,  clear  layer,  and  a  lower  yel- 
low one ;  the  former  is  fluid  intercellular  substance,  the  latter  contains 
chiefly  pus-corpuscles.  On  simple  microscopic  examination  these  are 
round,  finely  punctated  globules,  of  the  size  of  white-blood  corpuscles; 


gQ  GRANULATION  TISSUE. 

they  contain  three  or  four  dark  nuclei,  which  become  quite  distinct 
on  addition  of  acetic  acid,  because  it  dissolves  the  pale  granules  of 
the  protoplasm,  or  at  least  swells  them  so  that  they  become  transpar- 
ent. The  nuclei  are  not  soluble  in  acetic  acid  ;  the  entire  globule  is 
readily  dissolved  in  alkalies. 

Fig.  5. 

^^ 


{p. 


Pus-cells  friim  fresli  pus,  masnifiert  400  times,  a,  flca<l  without  addition  :  6,  the  same  colls  after 
addition  of  acetic  acid ;  c,  various  forms  that  living  pus-cells  assume  in  their  amceboid 
movements. 

At  a  and  b  we  see  the  pus-cells  as  they  usually  appear  when  we 
cover  a  drop  of  pus  with  a  thin  glass,  and  without  any  addition  ex- 
amine it  under  the  microscope.  The  above-mentioned  observations 
of  Vb7i  Recklltighausea  have  shown  that  only  the  dead  cells  have  this 
round  shape ;  if  we  observe  the  pus-cells  in  the  moist  chamber  on  a 
warmed  object-table  (according  to  31.  Schultze),  we  see  the  amoeboid 
movement  of  these  cells  most  beautifully.  These  movements,  which 
only  go  on  slowly  and  sluggishly  at  blood-heat,  become  more  rapid 
at  a  higher  temperature,  and  less  so  at  a  lower.  The  number  of  pus- 
cells  in  pus  is  so  great,  that  in  a  drop  of  pure  pus,  under  the  micro- 
scope, the  fluid  intercellular  substance  is  not  at  all  perceived.  Chemi- 
cal  examination  of  pus  is  difficult,  first,  because  the  corpuscles  can- 
not be  completely  separated  from  the  fluid;  also,  because  the  large 
quantities  of  pus  obtainable  for  chemical  examination  had  already 
been  a  long  time  in  the  body,  and  may  have  changed  morphologically 
and  chemically  ;  and  lastly,  because  chiefly  protein  substances  are  con- 
tained in  pus,  whose  perfect  sejDaration  hitherto  has  not  alwaj'^s  been 
possible.  If  we  let  pus  from  a  wound  stand  in  a  glass,  the  clear, 
bright-yellow  serum  usually  occupies  more  space  than  the  thick,  straw- 
yellow  sediment,  which  contains  the  pus-corpuscles.  Pus  contajns 
ten  to  sixteen  parts  of  firm  constituents,  chiefly  chloride  of  sodium ; 
the  ashy  constituents  are  about  the  same  as  those  of  blood-serum. 
Recent  examinations  of  pus  have  shown  that  myosin,  paraglobulin, 
protagon,  fiitty  acids,  leucin,  and  tyrosin,  are  constant  constituents. 
Pus  collected  in  the  body  does  not  readily  undergo  acid  fermenta- 
tion ;  pure  fresh  alkaline  pus  soon  becomes  sour,  however,  if  it  is 
left  standing  for  a  time  even  in  a  covered  glass. 

Let  us  now  return  to  the  granulation  layer,  where  we  have  still 
an  important  point  to  consider,  namely,  the  numerous  vessels,  which 


SIMPLE  INCISED   WOUNDS   OF   THE   SOFT   PA?tT.?.  81 

give  its  red  appearance.  The  extensive  vasciilar  loops  tliat  must 
form  on  the  surface  of  the  Avound,  and  which  in  the  diagram  (Fig.  C) 
are  too  small  and  too  feAV,  commence,  with  the  growth  of  the  surround- 
ing granulation  tissue,  to  elongate  and  become  more  tortuous ;  tow- 
ard the  fourth  or  fifth  day  new  vessels  develop  as  fine  lateral  capil- 
lary communication,  as  in  heahng  by  first  intention,  and  the  tissue  is 
soon  traversed  by  an  excessive  number  of  vessels,  which  have  so 
much  efiect  on  the  appearance  of  the  entire  granulation  surface  that 
it  is  hardly  recognizable  on  the  cadaver,  where  the  fulness  of  the  ves- 
sels is  wanting,  or  is  at  least  less  marked  than  during  life,  and  the 
tissue  consequently  appears  pale,  relaxed,  and  much  less  thick.  The 
question  arises,  Wlience  come  these  remarkable,  small,  gradually-con- 
fluent red  nodules,  which  are  visible  to  the  naked  eye  ?  Why  does 
not  the  surface  look  even  ?  Indeed,  this  is  frequently  the  case  ;  the 
granules  are  by  no  means  always  distinctly  defined ;  but  it  is  not  easy 
to  explain  the  cause  of  their  form.  It  is  usually  assumed  that  the 
granules  are  to  be  regarded  as  imitations  of  the  cutaneous  papillae; 
but,  independent  of  the  fact  that  it  is  incomprehensible  why  such 
structures  should  be  imitated  in  muscle  and  bone,  and  that  the  gran- 
ules are  usually  ten  times  as  large  as  the  cutaneous  papillae,  this  is 
no  real  explanation.  The  appearance  of  the  granules,  doubtless,  de- 
pends on  the  arrangement  of  the  vascular  loops  into  tufts,  on  certain 
boundaries  between  the  difi"erent  groups  of  vessels.  Hence  we  might 
suppose  that  the  vascular  loops  acquire  this  form  without  known 
cause.  Still,  it  seems  to  me  natural  to  compare  them  to  the  circum- 
scribed capillary  districts,  already  formed  in  the  normal  tissues,  of 
which  we  have  numerous  examples,  especially  in  the  skin  and  in  fat. 
You  know  that  every  sweat  and  sebaceous  gland,  every  hair-follicle 
and  fat-lobule,  has  its  nearly-closed  capillary  net-work,  and,  by  the 
enlargement  of  such  capillary  net-works,  the  peculiar  closed  vascular 
forms  of  the  granules  might  arise.  Jn  fact,  in  the  cutaneous  and 
fatty  tissue  you  will  find  the  individual  fleshy  growths,  particularly 
sharply  and  clearly  defined,  while  this  is  more  rarely  the  case  in 
muscle,  where  these  bounded  capillary  districts  do  not  occm-.  It  can 
only  be  decided  by  artificial  injections  of  fresh  granulations,  whetlier 
this  explanation  is  correct ;  till  then,  it  remains  simply  an  attempt 
to  refer  this  pathological  new  formation  to  normal  anatomical  con- 
ditions. 

The  following  sketch,  in  which,  on  account  of  the  great  enlarge  • 
ment,  and  the  small  injured  district,  nothing  can  be  seen  of  the  granu- 
lar layer,  may  serve  you  as  a  diagram  of  the  development  of  the  gran- 
ulation tissue  with  its  vessels,  and  of  its  relation  to  pus  and  to  the 
subjacent  matrix,  as  it  has  developed  from  Fig.  4. 
7 


82 


RESULTS    OF    GRANULATION. 


If  the  growth  of  the  granulations  was  not  arrested  at  some  point, 
a  constantly-growing  granulation  tumor  would  be  formed.  Fortu- 
nately, this  is  never  or  very  rarely  the  case.  You  already  know,  from 
the  representation  of  the  external  conditions,  that  when  the  granula- 
tions have  reached  the  level  of  the  cutis,  or  even  sooner,  they  cease 
to  grow  and  are  coated  with  epidermis,  and  retrograde  to  a  cicatrix. 
The  followino-  changes  occur  in  the  tissue  :  At  first,  in  the  granula- 
tion tissue,  as  in  the  edges  of  the  wound  in  healing  by  the  first  inten- 
tion, there  are  numerous  cells  which  are  destroyed.  Not  only  the 
millions  of  pus-cells  on  the  surface,  but  also  cells  in  the  depths  of  the 
granulation  tissue,  disappear  by  disintegration  and  reabsorptiou  ;  it  is 
very  probable  that  cells  from  the  granulation  tissue  may  pass  back  un- 
injured into  the  vessels,  as  we  shall  see  when  treating  of  the  organi- 
zation of  thromboses  of  the  vessels.  As  the  cells  retrograde,  fine  fat- 
granules  gradually  form  in  them,'  not  only  in  the  round  but  also  in 
the  spindle-shaped  ones ;  such  cells,  which  are  composed  of  very  fine 


FlQ.  6. 


Diagram  of  granulation  of  a  wonnd ;  the  layer  of  pnB-cells  ie  represented  ae  having  been  acted 
on  by  acetic  acid,  to  distin<ruish  the  pus-cells  in  the  figure  more  accurately  from  ihe  granu- 
lation cells.    Magn.fled  300-400  diameters. 


SIMPLE  INCISED   WOUNDS   OF  THE   SOFT  PARTS. 


83 


fat-o^lobules,  are  generally  ca]\ed  r/t'anular  cells  {KQruchenzellen)  ;  they 
often  occur  in  the  granulations,  as  above  described.  When  the  gran- 
ulation tissue  is  thus  diminished  by  atrophy  and  escape  of  the  cells, 
and  at,  the  same  time  the  new  formation  of  cells  ceases,  something  im- 


FiG.  T. 


^2^ 


Fatty  degeneration  of  cells  from  granulations.     Granulation-cells.     Magnified  about  500  diameters. 

portant  must  happen,  that  is,  the  gradual  consolidation  of  the  gelat- 
inous intercellular  tissue  to  striated  connective  tissue,  which  is 
brought  about  by  the  steadily  increasing  loss  of  water,  that  is  carried 
oflF  by  the  vessels  and  evaporated  from  the  surface  ;  then  the  remain- 
ing cells  at  once  assume  the  shape  of  the  ordinary  connective-tissue 

Fig.  T  a. 


a,  Epithelial  cells  from  frog's  cornea,  throwing  out  shoots  at  the  edge  of  a  loss  of  substance,    b,  Some 
cells  detached  from  such  a  border.    Magnified  about  660.    Ileiberg. 

corpuscles.  According  to  the  view  of  other  observers,  the  original 
intercellular  substance  entirely  disappears,  and  its  place  is  supplied  by 
the  protoplasm  of  granulation  cells,  which  transforms  into  fibrous  tis- 
sue. With  these  changes  which  take  place  from  the  periphery  tow- 
ard the  centre,  the  secretion  of  pus  on  the  surface  ceases  ;  at  the  very 


g^  RESULTS  OF  GKANULATION. 

circumference  of  the  wound  on  the  condensing  granulation  tissue 
epidermis  forms  and  quickly  separates  into  hard  epidermic  and  mucous 
layers  ;  according  to  J.  Arnold^  this  formation  takes  place  by  the  di- 
vision of  a  protoplasm,  at  first  entirely  amorphous,  in  the  immediate 
vicinity  of  the  existing  border  of  epidermis.  Lastly,  the  superfluous 
capillaries  must  be  obliterated;  few  of  them  remain  to  keep  up  the 
circulation  through  the  cicatrix.  With  their  obliteration  the  tissue  be- 
comes drier,  tougher,  contracts  more  and  more,  and  often  the  cicatrix 
does  not  acquire  its  permanent  form  and  consistence  for  years. 

The  whole  process,  like  all  these  modes  of  healing,  contains  much 
that  is  very  remarkable,  although  recent  investigations  have  explained 
many  of  the  more  minute  morphological  changes.  The  possibility, 
nay,  the  necessity,  under  otherwise  normal  circumstances,  of  arriving 
at  a  typical  termination,  is  the  chief  characteristic  of  those  new  forma- 
tions that  are  induced  by  an  inflammatory  process.  If  this  natural 
course  of  healing  does  not  take  place,  it  is  because  either  constitu- 
tional or  local  conditions  indirectly  or  directly  interfere,  or  because  the 
oro-an  attacked  is  so  important  to  life,  the  disturbance  to  the  entire 
body  so  severe,  that  there  is  death  of  the  organ,  or  of  the  individual, 
or  that  the  functional  disturbance  of  the  former  causes  the  death  of 
the  latter.  Every  new  formation,  due  to  inflammation,  always  has  the 
tendency  to  reach  a  certain  point,  to  retrograde,  and  pass  into  a  sta- 
tionary state,  while  other  new  formations  have  no  such  natural  termi- 
nation, but  usually  continue  to  grow. 

DiflFerent  as  healing  by  the  first  and  second  intentions  appears,  at 
the  first  glance,  the  morphological  changes  in  the  tissue  are  in  both 
cases  the  same  ;  you  only  need  to  divide  Fig.  3  at  a,  to  have  the  same 
picture  as  in  Fig,  6.  Observation  teaches  in  the  simplest  manner  that 
this  is  actually  so ;  if  a  wound  almost  healed  by  first  intention,  but 
not  yet  consolidated,  be  torn  open,  we  have  a  granulating  wound 
which  soon  suppurates.  You  will  hereafter  be  frequently  convinced 
of  this  in  practice. 

The  above  process  of  healing  by  immediate  adhesion  and  by  gran- 
ulation we  have  termed  traumatic  inflammation^  and  have  found  it 
identical  with  some  other  forms  of  inflammation  ;  it  has  also  been 
stated  that  a  marked  peculiarity  of  traumatic  inflammation  is,  that  in 
it,  without  some  further  cause,  the  irritation  in  the  tissue  does  not 
extend  beyond  the  immediate  vicinity  of  the  injury.  I  beg  you 
carefully  to  remember  this  limitation.  Aji  we  know  nothing  ac- 
curately about  the  chemical  changes  and  nerve-actions  in  the  in- 
flamed tissue,  while  we  do  know  the  morphological  processes  very 
accurately,  we  naturally  attend  most  to  the  latter  if  we  wish  to  de- 
fine and  generalize  the  term  "  inflammation."      I  will  briefly  take  up 


SIMPLE  IXCISED   WOUNDS   OF  THE   SOFT   PARTS.  85 

the  previous  views  on  this  subject  (p.  53).  "  Inflammation  "  is  a 
raodification  of  the  normal  physiological  processes  in  the  diflferent 
tissues  of  the  body,  a  "disturbance  of  nutrition"  {^Virchoic)  whose 
histopoetic  results  you  now  know  and  of  whose  destructive,  deleteri- 
ous actions  you  will  hereafter  hear.  Any  part  of  the  body  was  said 
to  be  "  inflamed  "  when  it  was  hot  and  red ;  as  it  is  then  generally 
swollen  and  painful  also,  this  name  is  applied  to  processes  where  the 
above  symptoms  occur.  The  word  inflammation  originated  when 
there  were  no  true  pathologico-anatomical  ideas  ;  even  the  oldest  ob- 
servers understood  that  something  unusual  was  going  on  in  the 
tissues,  that  they  were  much  heated  (mj^ammatio) ,  and  from  the  first 
this  process  has  been  regarded  as  an  intense  increase  of  the  vital 
processes.  As  they  could  not  understand  the  process  itself  any  bet- 
ter than  we  do,  they  considered  the  symptoms  and  the  results  of  the 
process,  just  as  we  do ;  so  that  doubts  often  arose  if  it  were  proper 
to  speak  of  inflammation  when  one  or  other  symptom  w'as  absent  or 
not  well  marked,  just  as  it  is  to-day.  We  now  know  that  inflammation 
is  not  an  existence  outside  of  the  body,  which  makes  its  way  into 
some  part  and  there  grows,  and  must  be  expelled  like  Beelzebub, 
and  we  know  why  "  tumor,  rubor,  calor,  dolor,"  are  caused  by  in- 
flammation, but  although  any  one  usually  recognizes  an  acute  inflam- 
mation as  such  and  designates  it  correctly,  it  still  remains  difiicult  as 
well  clinically  as  anatomico-pathologically  to  give  an  exact  definition 
of  "  inflammation."  There  is  no  difficulty  in  distinguishing  an  oak 
from  an  ass ;  but,  if  you  attempt  to  generalize  and  give  a  sharp  defi- 
nition between  plants  and  animals,  you  will  have  the  greater  difficulty 
the  more  you  know  of  the  details  of  botany  and  zoology.  The  word 
"inflammation"  is  in  use,  and  so  accurately  designates  those  pro- 
cesses to  which  it  was  first  applied,  that  it  would  be  useless  to  try  to 
root  it  out.  By  it  we  understand  the  above-described  combination 
of  processes  in  the  tissues,  which  in  the  present  case  arise  from  a 
purely  mechanical  irritation  (wound)  acting  only  once.  How  much 
hypergemia,  exudation,  and  new  formation  of  tissue  is  required  before 
we  can  term  the  process  inflammation  cannot  be  stated  absolutely. 
It  seems  to  be  agreed  by  surgeons  and  anatomists  to  designate  as 
"  inflammatory  "  the  purely  regenerative  processes^  that  is,  the  neo- 
plastic tissues,  which  directly  or  indirectly  replace  the  loss  of  sub- 
stance. If  w^e  consider  the  process  in  the  modern  histological  sense, 
it  cannot  be  accurately  defined  from  the  inflammatory,  slight  as  it  may 
be  occasionally.  From  a  purely  clinical  point  of  view,  the  distinction 
is  easier,  as  we  often  meet  cases  without  any  of  the  four  cardinal 
symptoms  on  the  edges  of  the  wound ;  and  still  the  difference  be- 
tween a  slight  redness,  swelling,  and  sensitiveness  of  the  borders  of 


86  PREPARATIONS  SHOWING  HEALING  OF  WOUNDS. 

the  wound  to  an  intense,  progressing  inflammation  over  the  entire 
affected  portion  of  the  body  is  only  one  of  degree.  Custom  has  here 
made  a  distinction ;  when  a  wound  heals  without  any  symptoms  of 
so-called  reaction  we  do  not  call  it  inflammation  of  the  wound,  but 
only  apply  this  term  when  the  symptoms  of  inflammation  are  very 
prominent  at  the  part  injured. 

I  deemed  it  necessary  to  speak  to  you  of  these  general  consider- 
ations on  inflammation,  so  that  you  might  early  learn  some  of  the 
difficulties  of  the  subject.  In  these  lectures  it  will  always  be  my  ob- 
ject to  explain  to  you,  as  clearly  as  is  now  possible,  the  anatomicO' 
physiological  disturbances,  and  at  the  same  time  to  show  you  histo- 
logically the  origin  of  the  clinical  descriptions  and  expressions  now 
in  use.  This  is  the  only  way  we  can  truly  ground  our  knowledge  ; 
without  understanding  this  you  would  always  be  feeling  around  the 
outside  of  symptoms,  and  by  clinging  to  certain  ones  fall  into  in- 
curable dogmatism,  which  in  a  country  doctor  the  world  calls  "  nar- 
row-mindedness," in  the  eminent  city  physician  "  infallibility."  As 
the  great  majority  of  men  are  stupid  in  physical  matters,  you  are 
sure  even  with  the  latter  peculiarities  of  attaining  great  practical 
success,  but  you  must  then  renounce  all  idea  of  appreciating  or  ad- 
vancing the  progress  and  development  of  society. 

It  is  not  the  object  of  these  lectures  to  show  you  on  preparations,  step 
by  step,  the  morphological  microscopical  changes  in  wounded  tissue — 
you  will  see  these,  in  the  practical  lessons  on  pathological  histology — 
but  I  will  show  you  a  few  points,  so  that  you  may  not  think  that  the  pro- 
cesses of  which  I  have  spoken  can  only  be  demonstrated  on  diagrams. 

The  cell-infiltration  of  tissue,  after  irritation  by  an  incision,  is  best 
seen  in  the  cornea.  Four  days  ago  I  made  an  incision,  with  a  lance- 
shaped  knife,  in  the  cornea  of  a  rabbit ;  yesterday  the  incision  was 
visible  as  a  fine  line  with  milky  cloudiness.  I  killed  the  animal  care- 
fully, cut  out  the  cornea,  and  let  it  swell  in  pyroligneous  acid,  till  this 
morning ;  then  made  a  section  through  the  wound,  and  cleared  it  up 
with  glycerine. 

Now,  at  a  a  (Fig.  8),  you  may  see  the  connecting  substances  be- 
tween the  edges  of  the  wound,  in  which  there  has  been  a  considerable 
collection  of  cells,  between  the  lamellae  of  the  cornea,  where  the  cor 
neal  corpuscles  lie.  These  cells  are  not  so  evident  in  the  method  em 
ployed  as  in  that  where  carmine  is  used,  still  the  intermediate  sub 
stance  between  the  edges  of  the  wound  is  very  distinct.  As  you  see 
it  consists  almost  entirely  of  cells ;  the  cells  alone  would  not,  however, 
render  the  union  sufficiently  firm,  if  they  were  not  glued  together  by 
a  fibrinous  cement.  The  young  cells  probably  come  out  of  the  edges 
of  the  wound  from  the  fissures  between  the  corneal  lamellas,  and  prob- 
ably do  not  originate  in  the  connective  substance  between  the  edges 


SIMPLE   IXCISED   WOUXDS   OF   THE    SOFT   PARTS. 


87 


of  the  wound ;  on  the  contrary,  the  latter  is  finally  formed  from  them. 
Let  me  remark  incidentally,  these  fine  corneal  cicatrices  subsequent- 
ly clear  up,  so  as  to  leave  scarcely  a  trace.  All  the  cells  that  you 
here  see  in  the  preparation  come  from  the  vascular  loops  of  the  con- 
junctiva ;  the  normal  stellate  corneal  cells  are  not  visible  here.  I  have 
chosen  this  specimen  because  the  intermediate  substance  is  broad  and 
very  rich  in  cells.  In  very  small  incisions,  made  in  the  cornea  with  a 
very  sharp  knife,  the  intermediate  substance  is  so  slight,  that  it  is  seen 
with  difficulty  ;  then,  too,  the  changes  on  the  edges  of  the  wound  are 
slighter  than  here,  and  so  slight  a  scar  is  not  visible  to  the  naked  eye. 
Here  (Fig.  9)  you  have  a  transverse  section  through  a  twenty-four- 

FiG.  8. 


Corneal  incieion  three  days  old ;  a  a,  the  unUing  substance  between  tbe  two  sides  of  the  iiiciB 
iou.    Majniifted  300  diameters. 

hour  old,  freshly-united  wound  in  the  cheek  of  a  dog.  The  incision  is 
well  marked  a,t  a  a  ;  the  edges  of  the  wound  are  separated  by  a  dark, 
intermediate  substance,  which  consists  partly  of  white  cells,  partly  of 
red  corpuscles — the  latter  belong  to  the  blood,  escaped  between  the 
edges  of  the  wound,  after  the  injury ;  the  connective-tissue  fissures 
crossed  by  the  wound,  in  which  the  connective-tissue  cells  lie,  are 
already  filled  with  numerous  newly-formed  cells,  and  these  cells  have 
already  pushed  into  the  extravasated  blood  between  the  edges  of  the 
wound.  I'he  preparation  has  been  treated  with  acetic  acid,  hence  you 
no  longer  see  the  striation  of  the  connective  tissue,  but  see  the  young 
cells  more  distinctly.  Look  particularly  at  certain  strings,  rich  in 
cells,  that  extend  from  the  wound  toward  both  sides  [b  b  b)  ;  these 
are  blood-vessels  in  whose  sheaths  many  cells  are  infiltrated ;  this  is 
apparently  because  here  many  white-blood  cells  have  passed  through 


88 


PREPARATIONS  SHOWIXG  HEALING  OF  WOUNDS. 


Incised  wound  twenty-four  hours  old,  in  the  cheek  of  a  dog.    Magnified  300  diametere. 


the  walls  of  the  blood-vessels,  or  are  about  to  do  so.  About  the 
I  ransformation  of  the  coagulated  blood  between  the  edges  of  the 
wound,  the  wound  thrombus,  we  shall  hereafter  speak  more  fullj 
when  treating  of  cicatrices  of  the  vessels  at  the  end  of  this  chapter. 

This  preparation  (Fig.  10)  shows  a  young  cicatrix,  nine  days  after 
the  injury. 

Fw.  TO. 


a-' '' 

Cicatrix  uins  days  after  an  incision  throajrh  the  lip  of  a  rabbit,  healed  by  first  intention.    Magci- 

fled  300  diameters. 


i 


The  connective  substance  {a  a)  between  the  edges  of  the  wound 
consists  entirely  of  spindle-cells  pressed  together,  wliich  are  most  inti- 
mately connected  with  the  tissue  on  both  sides  of  the  wound. 


S\ 


SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS. 


89 


Fine  sections  cannot  be  made  of  granulation  tissue,  just  taken 
from  a  wound ;  it  is  generally  a  very  difficult  subject  for  fine  prepara- 
tions. If  you  harden  the  granulation  tissue  in  alcohol,  color  the  see 
tion  with  carmine,  then  clear  it  up  with  glycerine,  you  have  a  speci 
men  like  Fig.  11. 

Fig.  n. 


"J^'IC 


(?1X  -..■ 


Granulation  tissue, 


■^. 


BMSWH 


MasTiifled  300  diameters. 


The  tissue  appears  to  consist  solely  of  cells  and  vessels,  with  verj 
thm  walls  ;  the  whole  tissue  is  shrunken  by  the  alcohol,  so  that  we 
here  see  nothing  of  the  mucous  intercellular  substance  which  is  al- 
ways present,  even  if  only  in  small  quantities,  in  healthy,  fresh  granu- 
lations. 

We  see  the  tissue  of  the  young  cicatrix  particularly  well  in  the 
following  preparation  (Fig.  12),  w^hich  was  taken  from  a  broad  cica- 
trix, following  granulation  and  suppuration,  in  the  back  of  a  dog, 
about  four  or  five  weeks  after  the  injury. 

FiQ.  12. 


Yonn2  cicatricial  tissue.    ilaf;nitieU  3UU  dis  meters. 


90 


PREPARATIONS  SHOWING  HEALING  OF  WOUNDS. 


The  preparation  has  been  treated  with  acetic  acid,  to  show  the  ar- 
rangement of  the  connective-tissue  cells,  that  have  formed  fiom  the 
granulation  tissue ;  a  a  a  are  partly  obliterated,  partly  still  permeable 
blood-vessels ;  the  connective-tissue  cells  are  still  relatively  large,  suc- 
culent, and  distinctly  spindle-shaped,  still  the  intercellular  substance  is 
richly  developed. 

To  study  the  state  of  the  blood-vessels  in  the  wound,  we  musl- 
make  injections ;  this  is  quite  difficult,  and  quick  success  often  depends 
on  a  lucky  chance. 

Via.  13. 


Uorizonta!  section  tliron^  the  ton»nc  of  a  dog,  near  the  enrface,  made  with  a  hroad  knifi;. 
Frontal  section  throusrh  the  tongue  after  injection  andhardcninir,  Ibrty-eiirht  hours  after  the 
injury.  Magnified  70^0  diameters  ;  after  iVyiDodzotf—a  a,  intermediate  substance  between 
tlie  edses  of  the  wound  (consisting  of  filamentary-looking  adhesive  material  and  extrava- 
sated  blood).  The  section  has  passed  throush  two  layers  of  muscle  crossing  each  other. 
Looping  of  the  vessels  with  dilatation  in  both  borders  of  the  wound ;  commeuciug  elonjf»- 
tion  of  the  loops  into  the  connective  substance. 


On  this  subject  we  have  the  recent  works  of  Wywochoff  and 
TJiiersc\  whose  results  in  the  main  agree  partly  M-ith  one  another, 
partly  with  my  investigations  on  this  subject.  Wywodzoff^  who  op- 
r.rated  on  dogs'  tongues,  gives  a  series  of  representations  of  the  con- 


SIMPLE   INCISED   WOUNDS   OF   TEE   SOFT   PARTS.  Q) 

dition  of  the  blood-vessels  in  various  stages  of  healing  of  the  wound, 
a  few  of  which  I  shall  demonstrate  to  you,  without,  however,  going 
into  the  more  minute  details  of  the  formation  of  vessels. 

Pio.  14. 


Similar  section  of  a  dog's  tongue  as  in  Fig.  18.-Cicatrix  (a)  ten  days  old  •  evervwlierp  an-s 


Fig.  15. 


oJ 


Similar  «ecfioii  of  a  do'^'a  tontrnp  oq  in  t       i       n 


Masrnifled  70-80  diameters :  after  Wywodzoff. 


92 


PREPARATIONS  SHOWING  HEALING  OF  WOUNDS. 


Tliis  (Fig.  16)  is  a  preparation  of  granulations  from  a  human  be- 
ing, where  the  vessels  were  tolerably  filled  by  natural  injection  ;  the 
vascular  loops  are  very  close  together  and  complicated  at  the  surface ; 
leep  down  the  vessels  run  nearly  parallel. 


Fig.  16. 


Grauulation  vessels.    Magnified  40  diameters. 


In  conclusion,  here  is  a  preparation  of  injection  of  the  lymphatic 
vessels  of  a  dog's  lip.  You  see  that  the  young  cicatrix,  on  the  seventh 
day,  when  it  still  consists  almost  exclusively  of  cells,  has  no  Ijorphatio 


Fio.  n. 


Bcven-c^dvs-old  wound  in  the  lip  of  a  dog.    Healing  by  the  first  intention.    Injection  of  the 
lymphatic  vessels :  a,  mucous  membrane ;  &,  young" cicatrix.    Magnified  20  diameters. 

vessels ;  these  cease  immediately  at  the  young  cicatrix ;  they  do  not 
form  in  the  cicatrix  till  the  fibrillar  connective-tissue  bundles  form. 
The  granulation  tissue  also  has  no  lymphatic  vessels ;  where  the  in- 


PREPARATIONS  SHOWIXG  HEALING   OF  WOUNDS.  93 

flammatoiy  new  formation,  where  the  primary  celhilar  tissue  forms, 
the  lymjih-vessels  are  mostly  closed,  partly  by  fibrous  coagulations, 
partly  by  new  cell-formations.  These  observations  have  also  been 
confirmed  quite  recently  by  Ldscli,  of  St.  Petersburg,  by  examina- 
tions of  traumatically  inflamed  testicles. 

[To  understand  the  difference  between  healing  by  first  intention 
and  by  granulation  or  second  intention,  you  must  remember  that  in 
the  former  the  cellular  cicatricial  tissue  directly  caused  the  union  of 
the  edges  of  the  wound,  and  subsequently  changes  to  connective 
tissue.  In  healing  of  a  wound  with  loss  of  substance  direct  union 
is  impossible  ;  the  cicatricial  tissue  must  first  replace  the  lost  sub- 
stance and  fill  up  the  space  between  the  edges  of  the  wound.  Many 
text-books  speak  of  healing  by  second  intention  simply  as  healing 
by  suppuration  ;  in  many  cases  this  name  does  not  apply  ;  it  may 
take  place  without  inflammation  and  consequently  without  suppu- 
ration, under  a  crust  formed  of  dried  primary  secretion  from  the 
wound.  But,  even  when  inflammation  occurs,  it  does  not  necessa- 
rily result  in  sujDpuration.  In  most  cases,  however,  there  is  suppu- 
ration with  moderate  inflammation,  resulting  in  granulation  tissue, 
with  such  an  escape  of  white  blood-cells  that  many  of  them,  espe- 
cially the  superficial  layer,  have  not  time  to  organize  to  firm  tissue, 
but  mingle  with  the  secretion  of  the  wound  to  form  pus. 

The  wound  may  be  covered  with  a  crust  of  blood  or  primary 
secretion  from  the  wound  ;  for  healing  to  occur  under  the  crust  the 
primary  secretion  must  be  scanty  and  the  conditions  favorable  for 
the  plasmatic  circulation,  so  that  too  much  tissue  shall  not  die  on 
the  surface  of  the  wound  ;  moreover,  all  external  influences  causing 
active  inflammation  must  be  excluded  so  that  formation  of  new 
cells  may  not  exceed  a  certain  point.  If  the  cell-infiltration  be  too 
active,  and  plasmatic  exudation  from  the  vessels  too  copious,  there 
will  be  suppuration  and  detachment  of  the  crust.] 


94  SIMPLE  INCISED  WOUNDS   OF  THE   SOFT   PARTS. 


LECTURE   V  III. 

Geucral  Eeaction  after  Injuiy.— Surgical  Fever.— Thaories  of  the  Fever.— Prognosis  — 
Treatment  of  Simple  Wovuds  and  of  Wounded  Persons.— Open  Treiitmeut  of 
Wounds. 

Gentlemen:  You  now  know  the  external  and  internal  minute 
processes  in  the  healing  of  wounds,  so  far  as  it  is  possible  to  follow 
them  with  our  present  microscopes. 

Of  the  wounded  person  we  have  not  yet  spoken.  If  you  have  crit- 
ically examined  his  condition,  you  will  have  noticed  changes,  which 
may  not  be  explained  by  cell-knowledge  (mit  Zellenweisheit),  and 
perhaps  not  at  all. 

Possibly  even  the  first  day  the  patient  may  have  been  restless 
toward  evening ;  he  may  have  felt  hot,  thirsty,  with  no  appetite,  some 
headache,  wakeful  at  night,  and  dull  the  next  morning.  These  sub- 
jective symptoms  increase  till  the  evening  after  the  next  day.  If  we 
feel  the  pulse,  we  find  it  more  frequent  than  normal,  the  radial  artery 
is  tenser  and  fuller  than  before ;  the  skin  is  hot  and  dry ;  we  find  the 
bodily  tempertaure  elevated ;  the  tongue  is  coated  and  readily  becomes 
dry.  You  already  know  what  ails  the  patient — he  has  fever.  Yes,  he 
has  fever ;  but  what  is  fever  ?  whence  comes  it  ?  what  connection  is 
therebetween  the  different  remarkable  subjective  and  objective  symp- 
toms ?  But  do  not  ask  any  more  questions,  for  I  can  scarcely  answer 
those  already  proposed. 

By  the  name  "  fever  "  we  designate  the  combination  of  symptoms 
which,  in  a  thousand  different  shapes,  almost  always  accompanies  in- 
flammatory diseases,  and  is  generally  apparently  due  to  them.  We 
know  its  duration  and  course  in  various  diseases;  still,  its  nature  is  not 
fully  understood,  although  it  is  better  known  than  formerly. 

The  different  fever  symptoms  appear  with  very  variable  intensity. 
Two  of  these  symptoms  are  the  most  constant,  viz.,  the  increase  of 
pulse  and  bodily  temperature ;  we  can  measure  both  of  them,  the  first 
by  counting,  the  latter  by  the  thermometer.  The  frequency  of  the 
heart's  beat  depends  on  many  things,  especially  on  psychical  excite- 
ment of  all  sorts;  it  shows  shght  differences  in  sitting,  lying,  standing, 


SURGICAL  FEVER.  95 

walking.  Hence,  there  are  many  things  to  which  we  must  attend,  if  we 
would  avoid  error.  However,  we  may  avoid  these  mistakes,  and  for 
centuries  the  frequency  of  the  pulse  has  been  used  as  a  measure  of 
fever.  Examination  of  the  pulse  also  shows  other  things  important  to 
be  known :  the  amount  of  the  blood,  tension  of  the  arteries,  irregu- 
larity of  the  heart-beat,  etc. ;  and  it  should  not  be  neglected  even  now 
that  we  have  other  modes  of  measurement  of  the  fever.  This  other, 
and  in  some  respects  certainly  better,  mode  of  measvu'ing  the  amount 
and  duration  of  the  fever  is  determination  of  the  bodily  temperature 
with  carefully-prepared  thermometers,  whose  scales  are  divided,  accord- 
ing to  Celsius,  in  one  hundred  degrees,  and  each  degree  in  ten  parts. 
The  introduction  of  this  mode  of  measurement  into  practice  is  due  to 
Von  Bdrensprung^  Traiibe,  and  Wunderlich  /  it  has  the  advantage  of 
graphically  presenting  the  measurements,  which  are  usuallj^  made  at 
9  A.  Ji.  and  5  p.  M.,  as  curves,  and  making  them  at  once  easily  read. 

A  series  of  observations  of  fever  in  the  normal  course  of  wounds 
shows  the  following  points :  traumatic  fever  occasionally  begins  imme- 
diately after  an  injury,  more  frequently  not  till  the  second,  third,  or 
fourth  day.  The  highest  temperature  attained,  although  rarely,  is 
104.5°  F.-105.5° ;  as  a  rule  it  does  not  rise  much  above  102°-103°, 
Simple  traumatic  fever  does  not  usually  last  over  a  week ;  in  most 
cases  it  only  continues  from  two  to  five  days ;  in  many  cases  it  is  en- 
tirely absent,  as  in  most  of  the  small  superficial  incised  wounds  of 
which  we  spoke  above.  Traumatic  fever  depends  entirely  on  the  state 
of  the  wound  ;  it  is  generally  of  a  remitting  t}^e ;  the  decline  may 
take  place  rapidly  or  slowly. 

From  these  observations  we  should  naturally  suppose  the  fever 
would  be  the  higher  the  more  severe  the  injury.  If  the  injury  be  too 
insignificant,  there  is  either  no  fever  or  the  increase  of  temperature  is  so 
slight  and  evanescent  as  to  escape  our  modes  of  measurement.  It  has 
been  thought  that  a  scale  of  injuries  might  be  constructed,  according  to 
which  the  fever  would  last  a  longer  or  shorter  time,  and  be  more  or 
less  intense,  in  proportion  to  the  length  and  breadth  of  the  wound. 

This  conclusion  is  only  approximately  correct,  after  making  very 
considerable  limitations.  Some  persons  become  feverish  after  very 
slight  injuries ;  others  do  not,  even  after  severe  ones.  The  cause  of  this 
difference  in  the  occurrence  of  traumatic  fever  depends  partly  on 
whether  the  wound  heals  with  more  or  less  inflammatory  symptoms, 
partly  on  unknown  influences.  We  cannot  avoid  the  supposition  that 
purely  indi\ddual  circumstances  have  some  influence  :  we  see  that,  from 
similar  injuries,  one  person  will  be  more  disposed  to  fever  than  an- 
otlier 

Before  going  on  to  examine  how  the  state  of  the  wound  is  related 


96 


SIMPLE  INCISED   WOUNDS  OF   THE  SOFT   PARTS. 


to  the  general  condition,  we  must  examine  the  latter  a  little  more 
carefully.     The  most  prominent  and  physiologically  the  most  remark- 
able symptom  of  the  fever  is  the  elevation  of  the  temperature  of  the 
blood,  and  the  consequent  increase  of  the  bodily  temperature.     All 
the  modern  theories  of  fever  turn  on  the  explanation  of  this  symptom. 
There  is  no  ground  for  supposing  that  in  fever  any  absolutely  new 
element  must  be  added  to  the  requirements  acting  for  the  preservation 
of  a  constant  temperature  in  the  body,  but  it  is  probable  that  the  fever 
temperature  is  caused  by  some  change  of  the  normal  requirements  of 
temperature,  which  vary  readily  with  circumstances.     When  you  re- 
member that  men  and  animals  in  the  varied  temperatures  of  summer 
and  winter,  in  hot  and  cold  climates,  have  about  the  same  temperature 
of  the  blood,  you  will  see  that  the  conditions  of  production  and  giving 
off  of  heat  are  susceptible  of  great  modification,  and  that  witliin  these 
conditions  there  may  very  possibly  be  abnormities  of  the  resulting 
bodily  temperature.     It  is  evident  ajv^iorl  that  an  increase  of  bodily 
temperature  may  depend  either  on  diminution  of  the  amount  of  heat 
given  off,  the  production  remaining  the  same,  or  on  increased  produc- 
tion, the  loss  of  heat  remaining  the  same   (other  relations  of  these 
factors  to  each  other  are  possible,  but  I  shall  pass  over  them,  to  avoid 
confusing  you  on  this  difficult  question).     The  decision  of  this  cardinal 
question  does  not  seem  possible  at  present ;  it  would  be  possible  by 
determining  and  comparing  the  quantity  of  heat  produced  in  fever 
and  in  normal  conditions,  by  the  so-called  calorimetrical  experiments 
on  men  and  large  warm-blooded  animals ;  but  hitherto  there  have  been 
great  difficulties  in  the  way  of  these  experiments.     Liehermeister  and 
Leyden  have  invented  methods  of  calorimetry,  that  seem  to  me  cor- 
rect; but  the  methods  and  conclusions  of  Liehermeister  have  been 
energetically  combated  by  Senator.     Hence,  in  regard  to  the  above 
questions,  we  are  still,  to  a  great  extent,  thrown  on  probability  and 
hypothesis.     As  the  production  of  heat  depends  cliiefly  on  oxidation 
of  the  constituents  of  the  body,  increase  of  the  latter  would  necessarily 
be  followed  by  increase  of  the  former  if  the  loss  of  heat  remained  the 
same.     Now,  since  the  amount  of  urea  is  regarded  chiefly  as  the  result 
of  the  burning  up  of  the  nitrogenous  bodies,  and  as  the  amount  of  urea 
excreted  in  fever  is  usually  increased,  and  the  weight  of  the  body 
rapidly  decreases,  as  appears  from  the  experiments  of  0.  Weber,  Lieher' 
meister,  Schneider,  and  Leyden,  this,  with  the  above-mentioned  calori- 
metric  experiments,  is  considered  strong  proof  that  in  fever  the  con- 
sumption is  greatly  increased,  and  that  consequently  more  warmth  is 
really  produced  than  in  the  normal  state,  more  than  can  be  disposed 
of  by  the  body  in  the  same  time.     Trauhe  gives  another  view  of  the 
occurrence  of  fever-heat :  he  asserts  that  every  fever  beffins  \Yiih.  ener- 


ELEVATION   OF  TEMPERATURE   IN   INFLAMMATION.  97 

getic  contraction  of  the  cutaneous  vessels,  especially  of  the  smallei 
arteries,  and  that  thus  the  giWng  off  of  heat  to  the  air  is  decreased,  and 
more  heat  collected  in  the  body,  without  its  actually  producing  more. 
Although  this  hypothesis  is  advanced  by  its  author  with  wonderful 
ability  and  acuteness,  and  is  apparently  supported  by  the  work  of 
Senator,  I,  with  most  pathologists,  cannot  agree  with  it,  especially  as 
the  premises,  the  contraction  of  the  cutaneous  vessels,  can  only  be  ac- 
knowledged in  the  cases  begining  with  chill ;  but  this  chill  is  by  no 
means  a  constant  symptom  in  the  fever.  Hence,  in  what  follow^s,  we 
shall  start  from  the  point  that  in  fever  there  is  increased  production 
of  heat.  Then  arises  the  c^uestion.  How  does  inflammation  generally, 
and  traumatic  inflammation  particularly,  effect  the  increase  of  bodily 
temperature '?    This  question  is  answered  in  various  ways : 

1.  At  the  point  of  inflammation,  as  a  result  of  the  lively  interchange 
of  tissue,  heat  is  produced ;  the  blood  flowing  through  the  inflamed 
part  is  warmed  more,  and  distributes  the  abnormal  amount  of  heat  here 
acquired,  to  the  whole  body.     That  the  inflamed  part  is  warmer  than 
the  non-iuflamed  is  readily  proved,  especially  in  superficial  parts,  as  in 
the  skin,  but  this  docs  not  prove  that  more  warmth  is  produced  here 
than  is  usual,  but  is  probably  simply  due  to  the  circulation  of  more  blood 
through  the  dilated  capillaries ;  if  the  inflamed  part  be  not  warmer  than 
the  blood  flowing  to  it,  it  is  not  probable  that  it  should  produce  heat. 
The  investigations  on  this  point  are  numerous  and  contradictory.    The 
tbermometrical  measurements  of  0.  Weber  and  Eiifschniidt  have  given 
various  results ;  usually  the  temperature  in  the  wound  and  in  the  rec- 
tum (which  has  about  the  warmth  of  arterial  blood)  were  equal ;  occa- 
sionally the  former  was  higher  than  the  latter,  sometimes  the  reverse  j 
the  difference  was  never  great,  not  being  more  than  a  few  tenths  of  a 
degree  in  any  case.     Recently  0.  "Weber  has  hit  on  a  new  method  of 
measurement,  the  thermoelectric :  by  his  very  difficult  investigations 
the  question  seemed  to  be  decided  that  the  inflamed  part  is  always 
warmer  than  the  arterial  blood ;  indeed,  that  the  venous  blood  coming 
from  the  seat  of  inflammation  is  warmer  than  the  arterial  blood  going  tc 
it.     Quite  recently  these  investigations  were  repeated  in  Konigsberg 
by  H.  tfacobson,  31.  Bernhardt,  and  G.  Laudien,  with  the  final  re 
suit  of  showing  no  increase  of  warmth  in  the  inflamed  part.     From  the 
contradiction  of  the  results  of  observation  it  is  impossible  to  form  a 
judgment  on  this  point.     Nevertheless  it  seems  certain  that  in  the  in- 
flamed part  there  is  not  enough  heat  produced  to  elevate  the  tempera- 
ture of  all  the  blood  in  the  body  several  degrees. 

3.  The  irritation  induced  by  the  inflammation  on  the  nerves  of  the 
mflamed  part  might  be  supposed  as  advancing  to  the  centres  of  the 
vasomotor  (nutrient)   nerves ;  the  excitement  of  the  centres  of  these 


98  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

nen-es  would  induce  increase  of  the  general  change  of  tissue  and  con- 
sequent increase  of  the  production  of  warmth.  This  hypothesis,  which 
is  supported  by  some  facts,  such  as  the  great  difference  in  febrile  irri- 
tability, and  which  I  formerly  maintained,  no  longer  appears  to  me 
tenable ;  it  is  opposed  by  the  experimental  researches  of  Breuer  and 
ChrobaJi,  which  prove  that  fever  occurred  even  when  all  the  nerves 
were  divided,  by  which  there  could  be  any  conduction  from  the  periph- 
eral injury  to  the  nerve-centres  ;  the  recent  investigations  oiLeyden  also 
oppose  this  hypothesis,  since  they  prove  that  there  is  no  constant  re- 
lation between  the  loss  of  nitrogenous  material,  or  consumption,  and 
development  of  warmth. 

3.  Since,  from  the  nature  of  the  process,  in  the  inflamed  part  some 
of  the  tissue  is  destroyed,  while  some  neAv  tissue  is  formed,  it  is  not 
improbable  that  some  of  the  products  of  this  destruction  enter  the 
blood,  partly  through  the  blood-vessels,  partly  through  the  lymph- 
vessels  ;  such  material  acts  as  a  ferment,  excites  change  in  the  blood, 
as  a  consequence  of  which  the  entire  amount  of  blood  may  be  warmed. 
We  might  also  admit  a  more  complicated  mode  of  development  of 
warmth,  which,  by  including  the  nervous  system,  might  in  some  re- 
spects be  more  serviceable  theoretically ;  the  blood  changed  by  taking 
up  the  product  of  irritation  might  prove  irritant  to  the  centres  of  the 
vaso-motor  nerves,  and  thus  induce  increased  production  of  warmth. 
The  decision  between  these  different  hypotheses  is  diflBcult ;  they  are 
all  about  equally  justifiable,  and  all  have  the  common  factor  of  pollu- 
tion of  the  blood  by  material  from  the  seat  of  inflammation  or  the 
wound,  which  is  recognized  as  having  an  effect  on  the  production 
of  heat ;  these  substances  must  have  the  effect  of  exciting  fever 
{a  pyrogenous  action).  This  was  to  be  proved.  It  has  been  proved 
by  experiments  of  0.  Weber  and  myself,  which  I  can  notice  only 
briefly  here.  In  most  open  wounds,  especially  in  contused  wounds, 
shreds  of  tissue  are  always  decomposed ;  in  many  idiopathic  inflam- 
mations, the  circulation  is  arrested  at  different  points  in  the  inflamed 
tissue,  and  there  is  partial  decomposition  of  these  dead  portions. 
Decomposing  tissue,  then,  was  an  object  to  be  examined  in  regard 
to  its  pyrogenous  action.  If  you  inject  filtered  infusions  of  this 
substance  into  the  blood  of  animals,  they  have  high  fever,  and  not 
unfrequently  die  with  symptoms  of  debility,  of  somnolence,  with  coin- 
cident bloody  diarrhoea.  The  same  effect  is  induced  by  fresh  pus  in- 
jected into  the  blood ;  a  weaker  effect  follows  the  employment  of  juice 
and  pus  serum  pressed  out  of  the  inflamed  part,  but  the  secretion 
from  the  wound  taken  during  the  first  forty-eight  hours  is  especially 
active.  Hence  the  products  of  decomposition,  as  well  as  those  of 
new  formation,  have  a  pyrogenous  action  in  the  blood.  These  prod- 
ucts are  of  a  very  complicated  and  variable  nature  ;    some  of  the 


PYROGEXOUS   MATERIALS.  99 

chemical  substances  in  them  have  been  independently  tested  in  re- 
gard to  their  fever-exciting  qualities :  we  ma}'  induce  fever  by  inject- 
ing leucin,  sulphuretted  hydrogen,  sulphides  of  ammonium  and  car- 
bon, and  other  chemical  substances  resulting  from  the  decomposition 
of  tissue,  or  even  by  injecting  water  ;  decomposing  vegetable  matter 
also  has  a  fever-exciting  effect.  Hence  there  are  no  specific  fever- 
exciting  substances,  but  the  number  of  pj^rogenous  materials  is  in- 
numerable. 

I  may  here  mention  that  the  bad-smelling  substances  developed 
by  the  decomposition  of  the  tissues  are  probabl}'  the  least  dangerous. 
I  intentionally  distinguish  the  products  of  decomposition  in  acute 
inflammations,  which  are  usually  odorless  at  first  (whose  activity  as 
poisons  we  first  learned  by  experiment),  from  those  of  decomposing 
dead  bodies,  which  generally  smell  bad  at  once,  although  their  pyro- 
genous  action  is  similar.  If  a  wounded  patient  has  fever,  it  is  for 
me  a  proof  that  there  is  decomposition  going  on  in  his  wound,  and 
that  the  products  have  passed  into  the  blood,  whether  the  wound 
smells  or  not. 

After  the  pyrogenous  effect  of  the  products  of  inflammation  and 
decomposition  had  been  absolutely  confirmed,  it  remained  to  be  proved 
that  this  material  could  be  taken  from  the  tissue  into  the  blood,  and 
to  be  shown  how  this  took  place.  For  this  purpose  it  was  injected 
into  the  subcutaneous  cellular  tissue,  where  it  spread  around  in  the 
meshes  of  the  tissue  ;  the  effect,  as  to  fever,  was  the  same  as  when  the 
injection  was  made  directly  into  the  blood ;  hence  the  pyrogenous 
material  is  absorbed  from  the  cellular  tissue.  Here  there  is  another 
observation  to  be  made :  after  a  time,  at  the  point  where  decomposing 
fluid  or  fresh  pus  has  been  injected,  there  is  severe  and  not  unfrequently 
rapidly  progressive  inflainmation.  For  instance,  I  injected  half  an 
ounce  of  decomposing  fluid  into  the  thigh  of  a  horse  ;  in  twenty-four 
hours  the  whole  leg  was  swollen,  hot,  and  painful,  and  the  animal  very 
feverish,  I  did  the  same  thing  with  the  same  result,  with  fresh  (not 
decomposing)  abscess  pus,  in  a  dog.  This  action  of  pus  and  putrefy- 
ing matter  in  exciting  local  inflammation  I  call  phlocjogenous.  All 
pyrogenous  substances  are  not  at  the  same  time  phlogogenous ;  some 
are  more  so  than  others,  and,  especiall}'  in  the  putrefying  fluids,  it 
makes  a  great  deal  of  difference  whether  the  poisonous  power,  which 
we  do  not  know  accurately,  is  present  in  greater  or  less  quantities. 

It  is  net  certainly  determined  whether  the  pyrogenous  materials 
enter  the  blood  through  the  lymph  or  blood-vessels;  they  may  vary  in 
this  respect.  Some  points  are  in  favor  of  the  reabsorption  taking 
place  chiefly  through  the  Ij'mphatics. 

There  is  still  something  to  be  said  about  the  course  of  the  fever 


100  SIMPLE   INCISED  WOUNDS   OF  THE   SOFT   PARTS. 

artificially  induced  in  animals.  The  fever  begins  very  soon,  often 
even  in  an  hour  after  the  injection;  after  two  hours  there  is  always 
considerable  elevation  of  temperature :  for  instance,  in  a  dog  whose 
temperature  in  the  rectum  was  103°  F,,  two  hours  after  an  injection  of 
pus  it  may  be  105°,  and  four  houis  after  the  injection  107°.  It  is  im- 
material whether  the  substance  be  injected  directly  into  the  blood  or 
into  the  cellular  tissue.  The  fever  may  remain  at  its  height  from  one 
to  twelve  hours,  or  even  longer.  The  defervescence  may  be  either 
gradually  or  by  crisis.  If  we  make  new  injections,  the  fever  increases 
ao-ain  ;  by  repeated  injections  of  putrefying  material  we  may  kill  the 
lai'gest  animal  in  a  few  days.  Whether  an  animal  shall  die  from  a 
single  experiment,  depends  on  the  amount  and  poisonous  qualities  of 
the  injected  material  in  relation  to  the  size  of  the  animal.  A  medium- 
sized  dog,  after  the  injection  of  a  scruple  of  filtered  decomposing  fluid, 
may  be  feverish  for  a  few  hours  and  be  perfectly  well  after  twelve 
hours.  Hence  the  poison  may  be  eliminated  by  the  change  of  tissue, 
and  the  disturbances  induced  by  its  presence  in  the  blood  ma}^  again 
subside. 

I  will  now  terminate  these  observations,  and  only  hope  I  may  have 
made  this  important  subject,  to  which  w'e  shall  frequently  return, 
comprehensible  to  you.  I  feel  convinced  that  traumatic  fever,  like 
any  inflammatory  fever,  essentially  depends  on  a  poisoned  state  of 
the  blood,  and  may  be  induced  by  various  materials  passing  from  the 
seat  of  inflammation  into  the  blood.  In  the  accidental  traumatic 
diseases  we  shall  again  take  up  this  question. 

Now  a  few  words  about  the  prognosis  and  treatment  of  sujipurat- 
ing  wounds. 

1\\Q  prognosis  of  simple  incised  wounds  of  the  soft  parts  depends 
chiefly  on  the  physiological  importance  of  the  wounded  part,  both  as 
regards  its  importance  in  the  body  and  as  regards  the  disturbance  of 
function  in  the  part  itself.  You  will  readily  understand  that  injuries 
of  the  medulla  oblongata,  of  the  heart,  and  of  large  arterial  trunks 
lying  deep  in  the  cavities  of  the  body,  should  be  absolutely  fatal. 
Injuries  of  the  brain  heal  rarely;  the  same  is  true  of  injuries  of  the 
spnial  medulla — they  almost  always  induce  extensive  paralysis  and 
prove  fatal  by  various  secondary  diseases.  Injuries  of  large  nervous 
trunks  result  in  paralysis  of  the  part  of  the  body  lying  below  the  seat 
of  injury.  Openings  into  the  cavities  of  the  body  are  always  very 
serious  wounds;  should  they  be  accompanied  by  injury  of  the  lung, 
intestines,  liver,  spleen,  kidney,  or  bladder,  the  danger  increases; 
many  of  these  injuries  are  absolutely  fatal.  Opening  of  the  large 
joints  is  also  an  injury  which  not  only  often  impairs  the  function  of 


TREATMENT   OF   SIMPLE   INCISED   WOUNDS.  loi 

the  joint,  but  is  often  dangerous  to  life  from  its  secoudar}^  effects. 
External  circumstances,  the  constitution  and  temperament  of  the  pa- 
tient, have  also  a  certain  influence  on  the  course  of  cure.  Another 
source  of  danger  is  the  accessory  diseases  which  subsequently  arise, 
and  of  which  unfortunately  there  are  many  ;  of  these  we  shall  here- 
after speak  in  a  separate  chapter.  You  must  for  the  time  being  con- 
tent yourselves  with  these  indications,  whose  further  elucidation 
forms  a  very  considerable  part  of  clinical  surgery. 

We  may  give  the  treatment  of  simple  incised  wounds  very  briefly. 

"We  have  already  spoken  of  the  uniting  of  wounds  without  loss  of 
substance,  and  the  proper  time  for  removing  the  sutures,  and  that  is 
about  all  that  we  can  regard  as  directly  affecting  the  process  of  heal- 
ing. Still,  as  in  all  rational  therapeutics,  here  it  is  most  important : 
1.  To  prevent  injurious  influences  that  may  interfere  with  the  nor- 
mal course  ;  2.  Carefully  to  watch  the  occurrence  of  deviations  from 
the  normal,  and  to  combat  them  at  the  right  time,  if  possible. 

If  we,  first  of  all,  limit  ourselves  to  local  treatment,  we  have  no 
remedy  for  decidedly  shortening  the  process  of  healing  by  first  inten- 
tion or  by  suppuration,  say  to  half  its  time  or  less.  Nevertlieless, 
most  wounds  require  certain  care,  although  innumerable  slight  wounds 
heal  without  being  seen  by  a  surgeon.  The  first  requirement  for 
normal  healing  is  absolute  rest  of  the  injured  part,  especially  if  the 
wound  has  extended  through  the  skin  into  the  muscles.  Hence,  in 
wounds  at  all  deep,  it  is  very  necessary  that  the  patient  should  not 
only  keep  his  chamber,  but  that  he  should  remain  in  bed  for  a  time, 
as  it  is  evident  that  the  movement  of  injured  parts,  especially  of  in- 
jured muscles,  must  interfere  with  the  process  of  healing.  The  sec- 
ond important  point  is  cleanliness  of  the  wound  and  its  vicinity. 
Formerly  it  vvas'alwaj'S  considered  necessary  to  cover  the  wound,  and 
to  apply  dressings  in  all  cases.  Of  late  I  have  grown  doubtful  if  this 
be  indeed  necessary  ;  indeed,  I  would  go  so  far  as  to  assert  that  in 
many  eases  it  is  well  not  to  apply  any  dressings.  In  wounds  that 
have  been  sewed  up,  it  has  often  been  observed  that  it  does  no  harm 
to  leave  them  uncovered.  If  we  wish  to  cover  sutured  wounds,  on 
account  of  pain,  redness,  and  swelling,  or  because  they  are  in  a  part 
of  the  body  upon  which  the  patient  must  lie,  we  may  apply  various 
kinds  of  dressing  ;  we  may  smear  the  edges  of  the  wound  with  pure, 
fine  oil,  best  with  almond-oil,  and  laj'  on  a  fold  of  linen  dipped  in  oil, 
which  should  be  changed  daily,  till  the  sutures  are  removed  ;  or  else 
we  may  apply  a  linen  compress  three  or  four  la\'ers  thick,  and  the 
size  of  the  wound,  wet  with  water*  and  cover  it  with  oil-silk,  gutta- 
percha sheeting,  or  parchment-paper,  and  make  a  few  loose  turns  of 
a  bandage  over  it. 


102 


SIMPLE   INCISED   WOUNDS   OF   THE   SOFT    PARTS. 


For  some  time  past  I  have  used  as  the  immediate  covering  of 
recent  wounds  merely  a  moistened  thin  sheet  of  gutta-percha,  over 
this  a  moist  compress  ;  and  to  prevent  the  latter  trom  drying,  i 
cover  it  with  some  waterproof  stuff,  such  as  glazed  paper,  gutta- 
percha, or  oiled  silk,  and  then  cover  with  plenty  of  dry  wadding  (de- 
prived'of  fat  and  made  bibulous  by  cooking  in  lye).  This  dressing 
may  be  removed  without  wetting  or  giving  pain  ;  it  is  to  be  retained 
in  place  by  a  bandage  or  adhesive  plaster.  For  moistening  the 
compresses  and  the  sheet  of  gutta-percha,  which  lies  directly  on  the 
wound,  we  generally  employ  liquids  which  arrest  the  decomposition 
of  the  secretion  from  the  wound  and  prevent  its  smelling  badly,  that 
is,  which  are  antiseptics  and  deodorants,  and  at  the  same  time  may 
destroy  any  infectious  matters  clinging  to  the  dressings.  In  my 
clinic,  for  this  purpose  Ave  employ  saturated  solution  of  chloride  of 
lime,  aqua  plumbi,  solutions  of  carbolic  acid,  carbolate  of  soda,  and 
sulphate  of  soda  (10  per  cent.).  I  have  not  noticed  any  decided 
difference  in  their  effect,  and  on  the  score  of  economy  use  solution 
of  chloride  of  lime  for  ordinary  di-essings. 

The  frequency  with  which  the  dressings  of  a  simple  wound  should 
be  renewed  depends  on  the  amount  of  secretion.  As  a  general  rule, 
during  the  first  four  days  the  dressing  above  described  should  be 
removed  at  least  twice  daily  ;  if  during  the  first  and  second  days 
the  secretion  escapes  in  a  few  hours,  the  dressing  should  be  changed 
at  onca.  In  doing  this  we  no  longer  need  to  use  a  syringe,  and  to 
carefully  work  off  the  charpie  from  the  wound,  while  the  patient 
suffers  tortures ;  should  it  ever  be  necessary  to  inject  fistulous 
wounds,  of  which  we  shall  hereafter  speak,  we  may  use  either  a  sim- 
ple syringe  or  an  Es}narcNs  douche,  which  consists  of  a  cylindrical 
vessel  25  centimetres  high  and  13  in  diameter,  A^th  a  short  tube  in- 
serted at  its  bottom,  on  to  w^hich  a  rubber  tube  with  a  nozzle  is 
applied ;  when  this  vessel  is  held  up  by  an  attendant,  it  acts  as  a 
syringe.  It  is  generally  enough  to  wipe  off  the  wound  with  a  little 
wadding  when  changing  the  dressing,  and  it  is  not  necessary  to 
remove  every  trace  of  pus. 

In  many  cases  this  dressing  may  be  continued  for  weeks,  being 
after  a  time  applied  only  once  daily,  and  then  every  two  or  three 
days;  cicatrization  goes  on  and  the  wound  heals  without  doing  any 
thing  more. 

Nevertheless,  independent  of  certain  diseases  of  the  granulations, 
of  which  we  shall  speak  more  particularly  hereafter,  it  frequently 
happens  that  under  a  continuance  of  the  same  treatment  the  heal- 
ing is  arrested  ;  for  days  the  process  of  cicatrization  does  not  ad- 
vance, and  the  granulating  surface  assumes  a  flabby  appearance. 


TREATMENT   OF  SIMPLE   INCISED   WOUNDS.  103 

Under  such  circumstances  it  is  advisable  to  change  the  dressing,  to 
irritate  the  granulating  surface  by  new  remedies.  These  temporary 
arrests  of  improvement  occur  in  almost  every  large  wound.  Under 
such  circumstances  you  may  order  fomentations  of  warm  camomile- 
tea  ;  several  compresses  may  be  dipped  in  the  warm  tea,  wrung  out, 
and  from  time  to  time  applied  fresh  to  the  wound ;  or  you  may  pre- 
scribe lotions  of  lead- water.  You  may  also  paint  the  wound  from  time 
to  time  with  a  solution  of  nitrate  of  silver  (two  to  five  grains  to  the 
ounce  of  water).  If  the  wound-surface  be  no  longer  large,  you  may 
finally  make  use  of  salves  ;  these  should  be  spread  thinly  over  charpie 
or  linen  ;  the  most  suitable  are  the  basilicon-ointment  (compound 
resin  cerate,  consisting  of  oil,  wax,  resin,  suet,  and  turpentine)  and 
a  salve  of  nitrate  of  silver  (one  grain  to  a  drachm  of  any  salve,  with 
the  addition  of  Peruvian  balsam).  If  the  cicatrization  be  already  far 
advanced,  we  may  employ  zinc-salve  (zinc,  oxide  3  j,  ung.  aq.  rosfe 
3  j),  or  let  the  dry  charpie  adhere,  and  have  the  last  portion  of  the 
wound  heal  under  the  scab. 

A  very  peculiar  and  occasionally  a  very  efficient  method  of  hast- 
ening cicatiization  of  granulating  wounds  has  been  introduced  b}' 
Meverdin.  He  found  that  a  small  portion  of  cutis  taken  from  the 
surface  of  the  boJy  with  concave  scissors,  and  fastened  with  the  raw 
surface  on  the  granulations  by  means  of  adhesive  plasters,  not  only 
becomes  adherent,  but  the  transplanted  epidermis  begins  to  grow 
and  forms  the  centre  of  a  so-called  cicatricial  island,  whence  the  skin- 
ning over  of  the  wound  advances  just  as  it  does  from  the  margins. 
In  the  clinic  we  have  often  resorted  to  this  artificial  skinning  over 
of  wounds  with  epidermis,  and  rarely  ineffectually.  The  effect  is 
perceived  when  we  remove  the  plaster  on  the  third  day  and  find  a 
red  aureola  around  the  transplanted  piece  ;  this  gradually  grows,  and 
on  the  sixth  or  eighth  day  is  followed  by  a  bluisii-white  border,  just 
as  in  cicatrization  at  the  edges  of  the  wound.  I  do  not  underestimate 
the  practical  value  of  this  proceeding,  but  it  is  even  more  interesting 
to  me  from  the  addition  it  forms  to  our  knowledge  of  natural  history. 
Here  we  have  the  most  striking  proof  not  only  of  the  independence 
of  cell-life  in  the  tissues  of  man,  but  still  more  of  the  readily-excited 
formative  power  of  the  epithelium,  which  is  here  aroused  by  a  change 
of  the  nutrient  material,  while  the  portion  of  the  papillary  lajer  of 
the  cutis  ti-ansplanted  at  the  same  time  does  not  grow. 

Thiersch,  Mintiich,  and  Menzel  have  made  observations  showing 
t-hat,  eight  hours  or  perhaps  longer  after  death,  epidermis  may  be 
successfully  transplanted.  The  finer  details  of  the  histological 
changes  in  these  transplantations  have  been  carefully  studied  by 
Keverdin,  and  still  more  so  by  Amahile.      Czerny  has  shown  that 


104  SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS. 

mucous  membrane  from  the  mouth  (with  flat  epithelium)  and  from 
the  nose  (with  cj^lindrical  ciliated  epithelium)  may  be  successfully 
grafted  on  wounds.  [Is  this,  perhaps,  one  cause  for  animals  licking 
their  wounds  ?]  The  epithelium  of  these  membranes  preserves  its 
character  but  a  short  time,  then  it  is  transformed  into  epidermis. 

[March  6,  1871,  Dr.  B.  Howard  presented,  at  the  meeting  of  the 
New  York  County  Medical  Society,  a  case  in  which,  after  skin-grafting, 
cicatrization  had  progressed  for  a  time,  then  seemed  to  be  arrested  ; 
whereupon  he  grafted  small  portions  of  the  biceps  muscle  and  thus 
induced  a  continuance  of  the  cicatrization.  The  question  was  raised 
whether  the  renewed  activity  was  not  due  to  the  previous  skin-gvaiit- 
ing.  Dr.  Stein  stated  that  he  had  aroused  these  old  ulcers  by  sprin- 
kling epidermis  scales  over  their  surface.] 

[It  is  not  yet  determined  which  of  the  constituents  of  the  pri- 
mary wound  secretions  have  most  pyrogenous  action.  We  know 
that  an  injection  of  leucin  may  induce  fever  without  exciting  local 
symptoms,  and  it  is  known  that  leucin  is  contained  in  the  lymph. 
It  would  seem  that  reabsorption  of  extravasated  blood  and  lymph, 
even  from  subcutaneous  wounds  where  there  has  been  no  decompo- 
sition, may  cause  fever  ;  as  we  sometimes  see  in  simple  fractures, 
where  a  few  hours  after  the  injury  there  is  marked  elevation  of 
temperature  without  any  sign  of  inflammation.  On  the  other  hand, 
a  compound  fracture  may  run  its  course  withoiit  fever,  if  the  secre- 
tions from  the  wound  escape  readily.  Hence  we  see,  it  is  not  the 
extent  or  severity  of  the  wound  that  induces  fever  a  few  hours  after 
the  injury.  Clinical  observation  seems  to  teach  that  reabsorption 
of  undecomposed  primary  secretion  may  often  induce  considerable 
rise  of  temperature,  but  generally  has  little  such  effect.  If  we  have 
a  wound  with  loss  of  substance  covered  by  a  crust  of  dried  secre- 
tion, and  inflammation  appears  around  it,  secretion  collects  under 
the  crust,  raises  it  up,  and  exposes  the  granulating  surface  ;  if  the 
secretion  be  reabsorbed  the  temperature  will  rise  in  proportion  to 
the  amount  of  pyrogenous  substance  taken  into  the  circulation. 
Observation  shows  that  decomposition  depends  on  the  presence  of 
microscopic  organisms,  which  act  as  ferments,  and  by  multiplying 
excite  decomposition.  For  their  increase  proper  nourishment,  moist- 
ure, and  heat  are  requisite,  and,  above  all,  the  presence  of  a  germ 
brought  in  contact  with  the  part  by  the  air  or  otherwise.  The  air 
18  the  usual  bearer  of  these  germs  ;  they  may  be  filtered  from  it  by 
cotton,  or  destroyed  by  heating  to  the  boiling-point  of  water. 

In  cleansing  a  wound  you  wish  to  get  rid  of  everything  that 
may  disturb  its  normal  course  ;  of  course  you  remove  all  foreign 
bodies  and  coagula  of  blood,  both  because  they  may  prevent  union 


TREATMENT  OF  SIMPLE  INCISED   WOUNDS.  105 

by  first  intention,  and  may,  from  contact  with  atmospheric  germs, 
be  infected  ;  at  the  same  time  you  wash  off  the  primary  wound 
secretion,  as  its  absorption  may  induce  fever  and  inflammation. 
Then  you  try  to  prevent  the  entrance  of  anything  that  may  excite 
decomposition,  by  disinfecting  with  some  fluid,  such  as  a  two-per- 
cent. soUition  of  carbolic  acid,  which  contains  no  ferment  ;  then 
keep  the  parts  at  rest. 

As  the  undecomposed  secretion  from  tbe  wound  has  only  a  tem- 
porary effect,  the  chief  aim  of  modern  surgery  is  to  prevent  decom- 
position in  the  wound,  and  as  these  decomposing  masses  are  called 
septic  matters  the  treatment  used  to  prevent  them  is  called  anti- 
septic. Animal  substances  are  more  readily  preserved  from  decom- 
position the  more  freely  they  are  exposed  to  air  ;  hence  wounds 
were  left  wide  open,  so  the  dead  tissue  might  dry  up  and  not  de- 
compose ;  this  is  the  open  treatment  of  wounds.  Healing  by  this 
method  would  be  slower  than  under  an  antiseptic  dressing. 

Pasteur  has  found  forms  of  vegetation  that  exist  without  oxy- 
gen and  are  even  killed  by  it ;  to  them  he  ascribes  great  activity, 
and  claims  that  they  are  the  sole  cause  of  septicemia.  This  ques- 
tion has  not  yet  been  fully  investigated  by  others. 

Experiments  seem  to  prove  that  the  sjyray,  with  two  to  five  per 
cent,  of  carbolic  acid,  in  Lister'^s  dressing,  is  unnecessary  and  often 
injurious.  It  does  not  prevent  the  entrance  of  germs  ;  in  fact,  may 
even  carry  them  into  the  wound.  Living  mi,crococci  have  been 
found  in  pus  from  acute  abscesses,  and  in  an  acute  inflammation  of 
the  medulla  of  bones,  hereafter  to  be  described,  decomposition 
within  the  bone  occurs  early.  Infection  from  within  could  hardly 
be  combatted  by  Listerism.  The  symptoms  of  poisoning  by  car- 
bolic acid  are  those  of  collapse,  fall  of  temperature,  vomiting, 
bloody  diarrhcea,  green  urine,  etc. ;  the  latter  symptom  occasionally 
occurs  without  others  ;  the  antidote  is  sulphate  of  soda  given  in- 
ternally :  it  probably  combines  with  the  carbolic  acid. 

Declat,  a  French  physician,  who  published  a  large  book  on  pho- 
nic acid,  in  Paris,  1865,  claims  that  most  of  the  evil  effects  of  car- 
bolic acid  are  due  to  impurities,  the  presence  of  cresylic  acid,  etc. 
He  gives  phenic  acid  alone,  or  combined  with  iodine,  sulphur,  or  ■ 
ammonia,  in  a  great  variety  of  diseases,  and  by  the  mouth,  rectum, 
and  hypodermically. 

Volkmanji  applies  the  antiseptic  dressing  as  follows  :  The  wound 
is  carefully  washed  with  a  two-per-cent.  solution  of  carbolic  acid, 
drainage-tubes  applied  through  it,  sutures  introduced,  a  narrow 
strip  of  gutta-percha  tissue  applied  over  the  wound,  compresses  of 
carbolized  gauze  as  large  as  a  handkerchief  are  applied  over  and 


106  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

around  the  wound  so  as  to  make  regular  pressure,  and  kept  in  place 
by  snugly  applied  bandages  of  carbolized  gauze  ;  this  is  covered  by 
a  large'  piece  of  gutta-percha  tissue  and  tightly  bandaged.  The 
bandage  is  to  be  removed  if  the  secretion  comes  through,  or  special 
symptoms  such  as  pain,  fever,  etc.,  develop.  If  there  is  fever,  in- 
quire about  the  bowels  ;  constipation  may  induce  a  rise. 

Dr.  Starcke,  in  the  Charite  Afinalen  of  Berlin,  1882,  in  an 
article  on  permanent  antiseptic  irrigation,  recommends  a  four-per- 
cenf.  solution  of  boracic  acid  with  0.1  per  cent,  thymol.  He  has 
abandoned  Butoid's  solution,  saying  "  it  forms  sediments  and  con- 
crements  in  the  sinuosities  of  the  wound,  and  thus  hinders  escape 
of  the  pus."  Starcke  thinks  the  wash  should  be  rather  warm  ;  he 
commenced  with  low  temperatures,  but,  as  detachment  of  necrosed 
parts  began,  used  the  wash  warmer,  and  found  it  better  borne.] 

Samuel,  who  in  his  last  work  on  fever  in  general  agrees  in  the 
etiology  given  in  this  chapter,  and  refers  the  increased  temperature 
to  increased  irritation  of  those  nerve-centres  which  cause  production 
of  warmth,  denies  the  existence  of  a  pyrogenous  poison,  and  brings 
up  some  strong  points  against  it ;  lie  thinks  that  the  blood-change 
which  is  the  final  essence  of  fever  is  always  the  same,  in  spite  of 
the  variety  of  forms  under  which  it  appears.  To  prevent  the  in- 
troduction and  removal  of  blood  and  water,  etc.,  from  being  re- 
garded as  pyrogenous  actions  in  the  broad  sense,  he  supposes  a 
similar  decomposing  tendency  of  the  blood  to  exist  between  the 
products  of  inflammation,  the  above-mentioned  and  other  influences, 
and  the  nervous  centre  which  is  to  be  excited  ;  and  this  is  termed 
the  true  final  pyrogenous  factor,  the  essential  element  of  fever. 

Regarding  constitutional  treatment,  we  can  accomplish  scarcely 
anything  with  internal  remedies  in  preventing  or  cutting  short  the 
subsequent  fever.  Still,  certain  dietetic  rules  are  necessary.  After 
the  injury  the  patient  should  not  overload  his  stomach,  but,  as  long 
as  he  has  fever,  must  live  on  low  diet.  This  he  usually  does  spon- 
taneously, as  fever  patients  rarely  have  any  appetite  ;  but,  even  after 
subsidence  of  the  fever,  the  patient  should  not  live  too  high,  but 
only  eat  as  much  as  he  can  digest  while  lying  in  bed  or  confined  to 
his  chamber,  where  he  has  no  exercise.  If  the  fever  be  high,  and 
the  patient  desires  some  change  of  drink  from  cold  water,  you  may 
order  acid  drinks,  as  lemonade  or  some  medicinal  substance  dis- 
solved in  water,  oatmeal  gruel,  barley-water,  etc.  We  may  give  the 
taste  of  the  patient  full  play  ;  but  it  is  well  for  you  to  attend  to  such 
things  yourself.  The  physician  should  know  as  much  about  the 
cellar  and  kitchen  as  about  the  apothecary-shop,  and  it  is  even  well 
for  him  to  have  the  reputation  of  being  a  gourmand. 


HEALING   BY   FIRST   AND    SECOND   INTENTION.  107 


LECTURE    IX. 

Combination  of  Healincj  by  First  and  Second  Intention.— Union  of  Granulation  Surfaces. 
— Healing underaScab.— Granulation  Diseases.— The  Cicatrix  in  various  Tissues; 
in  Muscle  ;  in  Nerve  ;  its  linobby  Proliferation  ;  in  Vessels.— Organization  of  the 
Thrombus. — Arterial  collateral  Circulation. 

To-day  I  have  first  simply  to  add  a  few  words  about  certain  de- 
viations from  the  ordinary  course  of  healing,  which  occur  so  fre- 
quently that  they  must  very  often  be  counted  as  normal;  at  all 
events,  as  very  frequent. 

It  is  not  at  all  unfrequent  for  the  two  forms  of  healing  above  de- 
scribed, by  first  and  second  intention,  to  combine  in  the  same  wound. 
For  instance,  you  unite  a  wound  completely,  and  may  sometimes  ob- 
serve that  at  some  places  there  is  healing  by  the  first  intention,  while 
at  others,  after  removal  of  the  sutures,  the  wound  gapes,  and  subse- 
quently heals  by  suppuration. 

But  it  is  much  more  common  for  a  large  and  deep  wound  to  heal 
superficially,  and  to  suppurate  for  some  time  from  the  deeper  part. 
If  the  entire  surface  of  the  wound  be  healthy,  the  cause  of  the  in- 
complete healing  is  either  that  it  was  imperfectly  coapted  at  the 
first  dressing,  or  that  blood  and  exudation  escaped  between  the 
edges,  wdiich  not  only  do  not  coagulate  firmly  enough  to  keep  up 
the  adhesion,  but  can  even  decompose  and  set  up  an  inflammation 
which  may  spread  rapidly  and  cause  severe  general  disturbances. 
These  important  results  of  such  wounds  compel  us  specially  to  study 
their  meclianical  conditions  and  chemical  changes  ;  from  the  first 
they  are  more  or  less  complete  Jistaloiis  xcouuds. 

It  may  be  readily  seen  that  where  the  skin  has  been  divided,  as 
for  the  removal  of  a  deeply -situated  tumor  or  a  portion  of  diseased 
bone,  a  cavity  is  left  if  the  skin  is  sewed  up,  which  will  remain  filled 
with  air  and  blood,  unless  the  bleeding  has  been  completely  arrested, 
the  w^ound  well  cleansed,  and  its  edges  brought  well  in  contact.  lu 
cases  where  different  tissues  are  wounded,  and  contract  unequally, 
as  in  a  wound  going  down  to  the  bone,  the  surfaces  would  be  very 
uneven  and  not  be  accurately  apposed  if  the  edges  of  the  skin  were 
simply  united.  Experience  teaches  that  in  such  cases  large  wounded 
surfaces,  even  if  loosely  approximated,  may  be  readily  separated  by 
secondary  hicmorrhages  or  fluid  exudations,  which  often  decompose 
while  the  skin  above  them  is  completely  united.  Then  the  parts 
around  the  wound  swell  and  become  painful,  and  high  fever  conies 
on.  I  will  not  here  describe  those  dangerous  states,  septic  phleg- 
mon and  blood-poisoning,  which  may  arise,  but  merely  say  that  we 


108  SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS. 

may  often  prevent  the  development  of  these  processes  by  early  evac- 
uation of  the  decomposing  matter.  It  is  not  the  mere  presence  of 
blood  between  the  tissues  that  causes  these  affections,  for  that  often 
occurs  in  severe  contusions  without  wounds  and  induces  no  bad  re- 
sults ;  it  is  the  decomposition  of  the  blood,  and  the  peculiarly  phlogo- 
genous  and  pyrogenous  properties  of  the  first  exudation,  which 
cause  the  danger.  Hence,  in  treating  these  wounds,  we  must  take 
care,  first,  to  prevent  collection  of  blood  and  secretion  in  the  wound, 
and  secondly,  in  case  this  has  not  succeeded,  to  prevent  decomposi- 
tion of  these  fluids,  so  that  they  may  rest  quietly  until  absorbed,  as 
they  would  if  the  skin  had  not  been  injured. 

Of  course,  if  there  be  no  blood  or  secretion  in  the  wound,  they 
cannot  decompose  ;  hence  it  is  most  important  to  prevent  their  col- 
lection. This  would  be  most  simply  prevented  by  not  closing  up 
deep  wounds,  but  filling  them  with  charpie,  wadding,  or  similar  bib- 
ulous material,  after  carefully  arresting  the  h.iemorrhage  ;  this  dress- 
ino-  must  be  renewed  as  often  as  it  becomes  saturated.  This  method 
was  used  for  years,  and  was  considered  satisfactory,  as  no  other  way 
was  known  ;  still,  as  we  now  know  better  methods,  we  think  the 
reaction  was  considerable,  although  less  than  accompanied  the  irri- 
tative treatment  of  the  middle  ages  ;  inflammations  spreading  from 
the  wound  were  frequent,  and  were  referred  to  individual  peculiari- 
ties, then  to  general  influences  of  the  atmosphere  or  to  hospital  air. 
It  is  only  within  the  last  twenty  years  that  the  propriety  of  the 
above  treatment  has  been  questioned,  and  new  ways,  based  on  differ- 
ent hypotheses,  have  been  sought.  This  led  to  two  opposite  meth- 
ods :  one  entirely  without  dressings  (open  treatment  of  wounds), 
the  other  accurate  closure  and  air-tight  dressing  (method  by  occlu- 
sion). In  the  open  treatment  of  Avounds,  which  can  only  be  used 
with  facility  in  wounds  of  the  extremities,  the  part  is  so  ]:)laced  that 
the  secretion  may  flow  readily  into  a  vessel  placed  beneath.  The 
first  two  days  this  secretion  is  of  a  dark  blood-color  and  thin  ;  from 
the  third  to  the  fifth  day  it  becomes  light  brownish,  tlien  yellow,  and 
soon  in  the  vessel  the  pus-serum  separates  from  the  lumpy  flakes  of 
pus-cells;  at  the  ordinary  temperature  of  the  room  this  secretion 
does  not  begin  to  smell  badly  in  twenty-four  hours,  unless  consider- 
able quantities  of  decomposing  dead  shreds  of  tissue  lie  in  the  wounds 
and  pass  off  with  the  secretion.  This  freedom  from  smell  must 
strike  any  one  who  has  smelt  dressings  that  have  been  removed  from 
a  wound  after  being;  applied  twenty-four  hours.  The  bodily  tem- 
perature to  which  this  secretion  is  subjected  while  in  the  dressing  is 
doubtless  the  cause  of  its  more  rapid  decomposition.  Should  one 
a  priori  suppose  that  with  such  a  dressing  collection  of  the  secretion 


OPEX   TREATMENT   OF   WOUXDS.  109 

with  its  evil  results  Avould  be  impossible,  he  will  soon  find  practi- 
cally that  the  object  of  the  open  treatment  of  wounds  will  not  be 
attained  by  absolute  inattention,  but  that  the  form  and  position  of 
the  wound  may  greatly  impede  the  escape  of  secretion,  and  also  that 
the  earl}',  firm  union  of  the  skin  may  shut  off  certain  parts  of  llie 
wound  as  effectually  as  if  a  suture  had  been  introduced,  and  thus 
the  same  severe  diseases  may  be  induced  as  by  the  old  methods  of 
treatment.  In  operations  we  may  do  much  to  make  wounds  of  such 
a  shape  that  the  secretions  will  run  off  at  once  ;  but  in  accidental 
wounds  this  is  often  difficult  to  do,  and  requires  a  certain  experi- 
ence. In  regard  to  the  above-mentioned  formation  of  pockets,  we 
should  prevent  it  by  daily  breaking  up  the  adhesion,  or  from  the 
first  lay  drainage-tubes  in  all  the  angles  and  hollows  of  the  wound, 
through  Avhich  any  secretion  from  the  deeper  parts  may  readily  es- 
cape. These  drainage-tubes,  introduced  by  CJiassaignac,  are  made 
of  vulcanized  rubber  of  various  calibre,  with  holes  along  the  sides. 
The  term  "  drainage "  is  taken  from  agriculture  ;  land  may  be 
drained  by  laying  a  system  of  porous  tubes  at  a  certain  depth 
through  the  soil ;  the  water  trickles  into  these  tubes,  and  flows 
throug-h  them  to  large  ditches.  The  results  from  careful  trial  of  this 
method  of  open  treatment  for  years  far  surpassed  all  previous  ones. 
From  the  publications  of  Martscher^  Vezin,  and  I^urozc,  I  had  my 
attention  called  to  this  plan  over  ten  years  ago  ;  and  as  it  fully 
agreed  with  the  views  I  had  arrived  at  from  clinical  and  experi- 
mental observations  and  investigations  on  the  poisonous  peculiarities 
of  the  first  secretion  from  wounds,  I  have  pursued  it  with  particular 
care,  and  have  resorted  to  it  in  almost  all  deep  wounds  of  the  ex- 
tremities, whether  incised  or  contused.  It  was  only  after  being 
assured  by  some  of  the  most  prominent  German  surgeons  that  better 
results  were  obtained  by  Lister'^s  careful  antiseptic  dressing  that  I 
would  trj'  it,  so  little  did  I  think  of  the  correctness  of  the  theor}'. 

There  is  no  doubt  that  it  would  be  a  great  advantage  for  the  pa- 
tient and  a  triumph  for  surgery  if  we  could  without  danger  induce 
healing  by  first  intention  in  all  large  deep  wounds.  It  is  true,  even 
in  the  open  treatment  of  wounds,  the  surfaces  may  so  ccme  in  con- 
tact as  to  heal  alinost  entirely  by  first  intention  ;  but  this  is  rare, 
although  partial  adhesions  are  frequent  and  do  not  require  breaking 
up  if  the  patient  remain  free  from  fever  and  pain.  Formerly,  by 
applying  bandages  to  press  the  surfaces  of  the  wound  together,  or 
by  deep  sutures,  attempts  were  made  to  induce  immediate  union  ; 
although  this  succeeded  in  some  cases,  it  proved  so  dangerous  in 
those  where  the  surfaces  of  the  wound  were  separated  by  blood  or 
exudation,  which  putrified  and  could  not  escape,  that  conscientious 


110  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 

surgeons  soon  abandoned  it.  Subsequently,  when  attempts  were 
made  by  laying  strips  of  oiled  rag  in  the  angle  of  the  wound  to 
give  exit  to  the  secretion,  it  rarely  succeeded.  In  my  opinion  Lis- 
ter deserves  great  credit  for  having  shown  that  numerous  drainage- 
tubes,  properly  placed  in  the  wound  and  cut  off  even  with  the  sur- 
face, will  completely  carry  off  all  secretion,  even  if  an  accurately- 
fitting  compressive  dressing  of  bibulous  material  be  applied  over  the 
unite's  wound ;  if,  by  directly  covering  the  wound  with  gutta-percha 
or  oiled  silk,  we  prevent  the  drainage-tubes  from  being  stuck  up  by 
dried  secretion,  such  a  dressmg  has  the  advantage  of  an  open  dress- 
ing, by  allowing  free  escape  of  secretion,  as  well  as  that  of  a  com- 
pressing dressing,  by  which  union  of  large  wounded  surfaces  is  so 
greatly  favored.  To  prevent  the  escaping  secretion  from  decom- 
posing in  the  dressing  and  affecting  the  wound,  the  dressing  should 
b3  frequently  changed  at  first.  In  this  care  about  dressings,  as  well 
as  in  cleanliness  about  operations,  it  seems  to  me,  lies  the  great  ad- 
vantao-e  of  Lister's  method.  But  Lister  started  on  the  construction 
of  his  complicated  dressing  from  different  ideas  ;  he  thought,  just  as 
I  have  repeatedly  asserted,  that  the  severe  inflammations  about 
wounds  and  the  constitutional  implications  are  almost  always  due  to 
decomposition  in  the  Avound.  I  think  that  decomposition  of  d^-ing 
tissue  and  exudation  from  the  wound  (for  us  a  decomposition  of 
albuminous  substances  with  formation  of  pyrogenous  and  phlogoge- 
nous  matters)  is  a  chemical  process  that  must,  under  certain  circum- 
stances, always  occur  in  these  substances  without  the  addition  of 
new  agents  ;  while  Lister  agrees  with  Pasteur'^s  view  that  decompo- 
sition only  occurs  under  the  influence  of  small  vegetable  organisms, 
just  as  he  claims  that  fermentation  is  only  developed  by  yeast  fun- 
gus. In  regard  to  this  question  of  living  or  dead  ferments,  I  must 
refer  you  to  organic  chemistry.  In  physiology  you  have  learned 
about  salivary,  pancreatic,  and  gastric  ferments,  which,  although 
produced  by  cell-activity,  no  longer  act  as  living  organisms,  but  in 
a  purely  chemical  way.  In  the  same  way,  I  think  a  substance  may 
be  formed  as  the  last  action  of  a  dying  tissue,  that  shall  have  some 
of  the  peculiarities  of  a  ferment,  and  at  the  same  time  have  a  phlogo- 
genous  action,  and  perhaps  be  very  poisonous  for  the  circulating 
blood.  It  does  not  seem  to  me  to  have  been  proved  that  the  addi- 
tion of  small  organisms  (vibriones  or  bacteria  of  Pasteur)  is  abso- 
lutely necessary  to  the  formation  of  such  substances.  It  is  true, 
they  are  generally  found  in  such  fluids  ;  but  this  may  be  explained 
by  the  fact  that  these  small  organisms  occur  everywhere  in  air  and 
water,  and  develop  particularly  in  decomposing  fluids. 

As  we  shall  often  have  occasion  to  speak  of  these  small  organ- 


ORGANIC  FERMENTS   IN   WOUNDS.  Ill 

isms  whose  significance  is  at  present  so  much  discussed,  I  will  here 
give  you  a  brief  sketch  of  those  forms  that  are  most  frequently  found 
in  decomposing  tissues  and  fluids.  They  may  be  minute  spheres 
(micrococcus,  from  fUKpbc,  small,  and  6  icoKKog,  the  germ),  or  minute 
rods  (bacteria,  from  ro  i3aKTTjpiov,  the  rod),  which  may  be  isolated, 
in  pairs,  or  in  chains  of  from  4  to  20  links  (streptococcus,  from  6 
OTpeTTTog,  the  chain,  and  6  KOKKog)  ;  often  they  are  held  in  the  shape 
of  a  sphere  or  cjdinder  by  a  glutinous  substance  which  they  throw 
out  (coccoglia,  from  icofcuog  and  ?)  yXia  or  yXoid,  glue). 


Fig.  17  a. 


■ip 


Q>o 


,  ,  CO    "»        o      0       n* 


■%  w 


c 

^^"'=f           « 

':-jao<rq        6 

",       "■fc*.' 

*""•      o    \,r 

^                       ♦ 

rP 

%         '^      \ 

^          o 

"oco 

Coo"   f^oo 

^'^     "      o" 

..=^      <too 

o,  Micrococcus  (Monads  of  Hiieter.  Microspores  of  Klfhs) :  6.  Coeco?Iia  or  Oliacoccns  (Zo<>gl<e&j 
Colin);  c,  Streptococcus  (Torula) ;  rf,  Bacteria;  «,  Vibrlones;  /,  Streptobacteria  (Leptothrix  of 
Hallier).    Magnified  300-500 

These  elements  vary  greatly  in  size,  from  a  pale  sphere,  of  such 
diameter  that  it  can  scarcely  be  perceived  wdth  the  liighest  power  of 
a  microscope,  to  the  size  of  a  pus-cell  ;  they  are  sometimes  mova- 
ble, at  others  quiet.  It  is  pretty  generally  agreed  that  these  minute 
organisms  are  vegetable  in  their  nature,  and  belong  to  the  algae ; 
but  their  accurate  botanical  position  and  relations  to  each  other  are 
still  matters  of  dispute  ;  their  development  is  not  yet  explained, 
and  until  very  recently  some  believed  that  they  were  the  result  of 
generatio  cequivoca  or  ahiogenesis,  that  is,  existed  without  influence 
from  any  living  organism.  From  ray  investigations,  T  think  tliat  all 
the  above  forms  belong  to  one  plant,  which,  being  composed  of  coc- 
cus and  bacteria,  and  being  found  chiefly  in  decomposing  fluids,  I 
have  called  Coccohacteria  septica.  This  plant  seems  to  me  to  de- 
velop as  follows  :  first,  its  germs  are  found  in  dry  air,  and   may  be 


112  SIMPLE   INCISED   WOUNDS   OF   THE   SOFT  PARTS. 

recognized  under  the  microscope  as  fine  dust ;  placed  in  water,  they 
swell  and  throw  out  more  or  less  small  pale  spheres,  micrococcus  {a, 
Fig.  21  a).  According  to  external  circumstances,  these  assume  the 
following  forms  :  1.  While  increasing  by  segmentation,  they  throw 
out  a  slimy  cement  (f/lia),  by  which  they  hang  together  in  balls,  like 
frog-spawn  (coccoglia,  or  gliaccccus,  b,  Fig.  21  a)  ;  on  the  surface 
of  fluids  this  form  often  appears  as  coherent  bright-brownish  mem-' 
branes,  and  it  also  grows  into  the  interstices  of  tissues,  and  is  found 
as  whitish-gray  flakes  in  fluids  ;  this  form  is  always  without  motion. 
Under  certain  circumstances  the  glia  around  these  spheres  and  cyl- 
inders thickens  to  a  membrane,  the  coccus  becomes  movable  and  es- 
capes through  an  opening  in  the  capsule  (ascococcus,  from  danog, 
tube).  2.  The  coccus  divides  always  in  one  direction,  and  some  of 
the  divisions  remain,  like  frog-spawn,  united  b\^  a  delicate  envelope 
of  glia  (c,  Fig.  21  a)  ;  these  streptococci  are  sometimes  in  motion, 
wriggling  slowly  across  the  field  of  the  microscope,  but  usually  they 
are  at  rest ;  we  may  find  them  in  fresh  secretion  from  the  wound  or 
in  pus,  and  often  in  alkaline  urine,  without  there  being  necessarily 
any  bad  odor ;  the  streptococcus,  along  Avith  the  isolated  micrococ- 
cus and  gliacoccus,  aie  the  forms  of  coccobacteria  which  occur  most 
frequently  in  decomposing  secretion  from  wounds  or  in  diplitheria 
of  wounds.  With  absolute  rest  the  streptococcus  may  form  long 
upright  filaments,  but  this  is  very  rare  in  living  organisms,  and  is 
difficult  to  see  under  the  microscope.  3.  The  coccus  grows  to 
rods,  which  increase  in  length  and  then  divide  across  ;  thus  we  have 
bacteria  chains  ( /',  Fig.  21  a),  which  may  be  moving  or  motionless. 
In  some  fluids  the  division  of  the  bacteria  goes  on  very  rapidly,  the 
rods  becoming  shorter,  till  they  are  finally  square  or  rounded  ;  and 
so  between  coccus  and  bacteria  there  are  numerous  transition  forms. 
Bacteria  are  not  apt  to  enter  the  secretion  from  wounds,  pus,  or 
decomposing  blood  ;  on  the  other  hand,  they  develop  and  remain  in 
all  fluids  of  the  cadaver  and  in  watery  exudations  of  almost  all  tis- 
sues ;  in  the  latter  they  are  very  movable. 

All  of  these  vegetations  require  plenty  of  water  and  organic 
substances,  especially  nitrogenous  matters,  for  their  rapid  propaga- 
tion ;  they  bear  abstraction  of  water  up  to  a  certain  point,  but  if 
entirely  dtied  out  they  die ;  and  although  they  will  subsequently 
swell  if  placed  in  water,  they  have  lost  their  power  of  vegetating. 
They  can  bear  temperatures  as  low  as  the  freezing  point,  and  nearly 
tip  to  the  boiling  point  ;  but  when  it  reaches  the  boiling  point  they 
die.  ^  In  fluids  or  moist  tissues  completely  excluded  from  atmos- 
pheric air,  they  will  vegetate  till  all  the  air  contained  in  the  fluid 
has  been  used  up ;  then,  no  more  air  being  absorbed  by  the  fluid, 


ORGANIC  FERMENTS  IN  WOUNDS.  113 

the  coccobacteria  die,  as  they  cannot  cause  decomposition  of  water 
or  any  organized  combination. 

Under  these  conditions  some  of  these  coccobacteria  may  be 
thrown  into  the  atmosphere  and  be  generally  distributed  by  the 
evaporation  of  fluids,  so  common  in  nature.  Still,  when  the  air  be- 
comes very  dry,  these  vegetations  might  dry  out,  die,  and  become 
organic  but  no  longer  organizable  dust  ;  but  such  an  occurrence  is 
provided  against.  As  in  many  of  the  algae  of  stagnant  water,  hav- 
ing similar  peculiarities  and  subject  to  being  dried  out,  so  in  some 
of  the  elements  of  coccobacteria  a  larger  quantity  of  peculiarly  con- 
centrated protoplasm  unites  to  form  a  glistening  sphere  with  dark 
contours,  which  may  be  distinguished  from  other  coccus,  but  hardl}' 
from  fat  globules.  These  little  spheres  have  the  peculiarities  of 
fungus-germs  and  very  resistant  seeds ;  they  may  be  entirely  dried, 
cooled  far  below  the  freezing  and  warmed  above  the  boiling  point, 
and  kept  hermetically  closed  for  a  long  time,  without  losing  their 
germinal  activity  ;  hence  they  are  calle  3  permanent  germs  {Dauer- 
sporen).  According  to  my  experience,  they  form  very  certainly  and 
not  very  rarely,  under  certain  circumstances,  in  bacteria  ;  but  they 
also  occur  in  coccoglia  balls ;  I  cannot  state  whether  some  spheres 
of  streptococcus  also  become  permanent  germs.  These  Daxiersporen 
are  the  dried  germs  from  which  we  started  for  development  ;  they 
require  quiet  in  or  on  some  fluid  or  moist  body. 

I  have  here  given  you  a  brief  review  of  the  results  to  which  my 
investigations  on  this  point  have  led.  But  I  must  call  attention  to 
the  fact  that  botanists  have  not  yet  proved  the  correctness  of  my 
views,  and  that  they  are  at  variance  with  those  of  most  others  who 
have  investigated  this  subject,  and  who  consider  each  of  the  forms 
above  described  as  separate  plants,  and  also  make  numerous  species 
of  each  kind,  especially  according  to  the  diseases  induced  by  each. 
Let  me  also  remind  you  that  most  pathologists  term  these  algte  fungi, 
and  often  call  them  all  bacteria. 

It  is  to  these  small  organisms  that  Pasteur,  and  after  him  Lister, 
attributes  decomposition,  at  least  those  forms  of  it  whose  products 
are  local  and  general  poisons.  If  we  could  prevent  their  entrance 
into  the  wound  or  its  secretions,  according  to  this  view,  there  would 
be  no  decomposition  of  the  secretions,  even  if  some  of  them  did  re- 
main in  the  wound.  With  this  idea,  Lister  writes  a  number  of  rules 
to  be  followed  in  the  operation  and  dressing  of  the  wound,  all  aim- 
ing at  the  destruction  of  the  germs  of  coccobacteria  which  might 
reach  the  wound  through  the  hands  of  the  operator  and  assistants  or 
the  air.  After  the  operator  and  assistants,  before  each  operation  or 
dressing,  have  carefully  washed  with  soap  and  water,  they  dip  their 
9 


114  SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS. 

hands  in  a  five  per  cent,  solution  of  carbolic  acid ;  in  the  same  way 
the  parts  about  the  seat  of  operation  are  to  be  carefully  washed  and 
moistened  with  the  same  solution  of  carbolic  acid;  and  all  instru- 
ments, sponges,  and  dressings  used  lie  in  this  solution,  which  is  sup- 
posed to  kill  all  germs  of  coccobacteria.  To  prevent  these  germs 
from  reaching  the  wound  through  the  air  during  the  operation  and 
dressing,  a  two  per  cent,  solution  of  carbolic  acid  is  constantly 
sprayed  on  the  part  with  a  special  apparatus,  so  that  it  falls  on  the 
wound  in  the  form  of  a  fine  rain.  We  have  already  described  the 
occlusion  or  "antiseptic"  dressing,  as  it  is  termed,  although  the 
open  treatment  of  wounds  and  some  other  methods  are  just  as  anti- 
septic. There  is  no  reason  for  going  any  further  into  details  here, 
where  we  are  chiefly  explaining  principles.  Lister's  dressing,  which 
seems  so  complicated,  is  in  practice  much  simpler  than  would  appear 
from  the  description ;  for  every  step  and  rule  the  inventor  had  a 
definite  reason,  and  there  is  nothing  arbitrary  or  intentionally  mys- 
terious. If  we  inquire  into  the  practical  working  of  this  treatment, 
we  hear  chiefly  praise,  and  many  speak  enthusiastically  of  its  won- 
derful effects.  Although  my  own  experience  with  it  is  not  very 
great,  I  can  recommend  it  as  being  generally  very  good  ;  it  is  cer- 
tainly more  popular  than  the  open  treatment  of  wounds ;  it  is  still  a 
disputed  point  which  of  these  methods  answers  best  in  treatment  of 
wounds  of  the  extremities.  I  urgently  recommend  you  to  perfect 
yourselves  in  the  principles  and  practical  application  of  Lister''s 
treatment,  and  you  will  have  many  favorable  results. 

It  is  diff"erent  if  we  accurately  examine  the  correctness  of  the 
theoretical  views  from  wliich  Lister  starts,  and  inquire  whether  by 
his  mode  of  operating  and  dressing  he  has  attained  his  object.  In 
regard  to  the  latter  point,  it  has  been  often  proved  that  in  the  secre- 
tion of  wounds  treated  according  to  ii'.s^er's  method,  and  which  healed 
rapidly  without  reaction,  coccobacteria  were  found  about  as  often 
as  in  secretion  from  wounds  which  were  merely  dressed  with  attention 
to  cleanliness.  This  shows  :  1,  that  the  presence  of  these  vegetations 
in  itself  proves  nothing  about  the  phlogogenous  or  other  poisonous 
qualities  of  the  secretion  ;  2,  that  Lister''s  dressing  is  no  guarantee 
for  the  destruction  of  bacteria.  Against  this  second  point  it  might 
be  urged  that  there  is  no  proof  that  these  germs  reach  the  wound 
on^y  from  without;  it  is  possible  that  permanent  germs  enter  the 
blood  through  the  respired  air,  and,  though  they  may  not  develop 
under  normal  circumstances,  do  so  in  the  secretion  of  wounds.  If 
this  be  possible,  there  is  no  sense  in  the  theory  of  Lister's  method 
as  far  as  regards  its  attacking  organic  germs  by  chemical  means. 
Indeed,  it  is  my  opinion  that  those  not  very  frequent  cases  where 


HEALING  BY  THIRD  INTENTION.  115 

coccobacteria  vegetations  have  been  found  in  completely  closed 
deeply-seated  points  of  inflammation,  which  never  communicated 
with  the  air,  can  only  be  explained  in  the  way  above  mentioned. 
Apart  from  the  fact  that  Lister's  dressing  is  expensive  if  followed 
out  in  all  its  details,  and  that  more  or  less  severe  poisoning  is  often 
caused  by  the  annoying  dermatitis  induced  by  the  carbolic  acid,  this 
incongruence  of  theory  and  practice  has  led  to  the  employment  of  more 
and  more  dilute  solutions  of  carbolic  acid,  and  its  replacement  by 
other  antiseptic  and  less  irritating  acids  and  salts  (salicylic  acid, 
Thiersch;  sulphide  of  sodium,  Hinich).  Various  changes  have 
also  been  made  in  the  mode  of  applying  the  dressing  (  Volkmann, 
Bardelehen)  ;  the  spray  has  been  entirely  omitted,  and  in  its  place 
after  the  operation  the  wound  has  been  washed  with  a  more  concen- 
trated antiseptic  solution,  etc.,  etc.  Thus  Lister^s  dressing  has 
been  variously  modified,  and  from  each  modification  the  same  favor- 
able results  have  been  obtained  as  from  the  original  dressing.  This 
confirms  me  in  the  opinion  formed  when  this  method  was  first  de- 
scribed, and  which  I  have  already  stated,  that  the  scrupulous  clean- 
liness and  the  careful  removal  of  secretion  from  the  wound  is  the 
most  important  part  of  it,  and  that  it  is  chiefly  popular  among  sur- 
geons who  formerly  paid  less  attention  to  these  points,  and  left  the 
dressings  to  the  dirty  hands  of  nurses  or  to  careless  students  or 
young  physicians,  while  now  the  dressings  are  all  applied  according 
to  definite  principles  of  cleanliness.  Moreover,  the  constantly 
spreading  and  more  energetically  preached  doctrine  of  local  infection 
from  wounds,  of  which  w^e  shall  treat  hereafter,  has  led  to  a  rec- 
ognition of  the  necessity  of  a  rational  treatment  of  wounds,  and 
has  contributed  essentially  to  opening  the  way  for  the  open  treat- 
ment of  wounds — to  Listerh  method  and  antiseptic  lotions. 


There  is  still  another  mode  of  adhesion  of  the  edges  of  wounds, 
which  consists  in  the  direct  union  of  two  adjacent  granulating  sur- 
faces. This  mode  of  healing,  which  you  may  call  healing  by  the  third 
intention,  is  unfortunately  very  rare.  The  reason  of  this  is  evident : 
pus  is  constantly  secreted  from  the  surface  of  the  granulations,  and 
while  this  goes  on  the  surfaces  are  only  apparently  in  contact,  for 
there  is  pus  between  them.  Occasionally,  it  is  true,  we  may,  by  press- 
ing the  two  granulation  surfaces  together,  prevent  the  further  forma- 
tion of  pus,  and  then  the  two  surfaces  may  adhere  ;  we  accomplish  this 
by  drawing  the  flaps  of  the  wound  firmly  together  with  good  adhesive 
plaster,  or  by  the  application  of  secondary  sutures,  for  which  it  is  well 
to  employ  wire.     Unfortunately,  the  attempt  to  hasten  the  cure  by 


116  SIMPLE  INCISED  WOUNDS   OF   THE   SOFT   FARTS. 

these  means  so  rarely  succeeds,  that  they  are  only  exceptionally  env 
ployed.  The  best  results  are  obtained  from  secondary  sutures  when, 
six  or  seven  days  after  the  injury,  they  are  applied  about  four  or  five 
lines  from  the  edge  of  the  wound,  because  the  tissue  is  then  more 
dense  and  firm,  and  the  sutures  cut  through  less  quickly. 

There  is  still  another  mode  of  healing,  viz.,  healing  of  a  superficial 
wound  under  a  scab.  This  only  occurs  frequently  in  small  wounds, 
that  secrete  but  little  pus,  for  in  these  alone  does  the  pus  dry  on  the 
wound  to  a  firmly-attached  scab ;  in  profuse  suppuration  it  is  true  the 
superficial  layer  of  the  pus  may  dry  by  evaporation  of  the  watery 
portion,  but,  while  new  pus  is  constantly  being  ^ecreted  under  it,  it 
cannot  form  an  adherent,  consistent  scab.  When  such  a  scab  has 
formed,  the  granulation  tissue  develops  to  only  a  very  small  amount  un- 
der it ;  perhaps  because  on  account  of  the  slight  pressure  of  the  scab,  the 
granulation  tissue  is  less  mucous,  so  that  the  epidermis  can  more 
readily  regenerate  under  the  scab ;  such  a  small  wound  may  be  wholly 
cicatrized  when  the  scab  falls. 


The  granulation  surface  may  assume  a  totally  diiferent  appearance 
from  that  above  described,  especially  in  large  wounds.  There  are 
certain  diseases  of  the  granulations,  whose  marked  forms  I  shall 
briefly  sketch  for  you,  although  the  varieties  are  so  numerous  that  you 
will  only  learn  them  from  individual  observation.  We  may  divide 
granulation  surfaces  as  follows : 

1.  Proliferating  fungous  granulations.  The  expression  "  fungous ' 
means  nothing  more  than  "  spongy ; "  hence  by  fungous  granulationb 
we  mean  those  that  rise  above  the  level  of  the  skin,  and  lie  over  the 
edges  of  the  wound,  like  fungus  or  sponge.  They  are  usually  very 
soft ;  the  pus  secreted  is  mucous,  glairy,  tenacious ;  it  contains  fewer 
cells  than  good  pus,  and  most  of  the  pus-cells,  like  granulation-cells,  are 
filled  with  numerous  fat-globules  and  mucous  material,  which  is  also 
more  abundant  than  normal  as  intercellular  substance ;  and  in  these 
granulations  Rindfleisch  also  discovered  collections  of  Virchow^s 
mucous  tissue,  fully  developed.  The  development  of  vessels  may  be 
very  prolific ;  the  fragile  tissue  often  bleeds  on  the  slightest  touch  ; 
occasionally  the  granulations  are  of  a  very  dark  blue.  In  other  cases 
the  development  of  vessels  is  very  scanty,  often  to  such  a  degree  that 
the  surface  is  light  red,  or  in  spots  has  even  a  yellowish,  gelatinous 
appearance,  in  very  ansemic  persons,  often  also  in  youiig  children  and 
very  old  persons.  The  most  frequent  cause  of  development  of  such 
proliferating  granulations  is  any  local  impediment  to  the  healing  of 
the  wound,  such  as  rigidity  of  the  surrounding  skm,  so  that  the  con 


DISEASES   or   THE   GRANULATIONS.  117 

traction  of  the  cicatrix  is  difficult;  a  foreign  body  at  tlie  bottom  of  a 
tubular  granulating  wound  (a  fistula)  ;  this  abnormal  proliferation  is 
also  particularly  apt  to  occur  in  large  wounds,  which  can  only  contract 
slowly ;  it  appears  as  if  tlie  activity  of  the  tissue  was  occasionally  ex- 
hausted, and  no  longer  capable  of  continuing  the  requisite  condensa- 
tion and  cicatrization,  so  that  it  only  produces  relaxed,  spongy  granu- 
lations. As  long  as  there  are  granulations  of  the  above  character^ 
rising  above  the  edges  of  the  skin,  cicatrization  does  not  usually  prO" 
gress.  The  wound  would  probably  heal,  but  not  for  a  very  long  time. 
We  have  plenty  of  remedies  for  hastening  the  healing  under  such  cir- 
cumstances ;  these  are  especially  caustics,  by  which  we  partly  destroy 
the  granulation  surface,  and  thus  excite  a  stronger  growth  from  the 
depth.  At  first  you  may  cauterize  the  granulating  surface  dailv,  es- 
pecially along  the  edges,  with  nitrate  of  silver,  whereupon  a  white 
slough  will  quickly  form,  which  will  become  detached  in  twelve  to 
twenty-four  hours,  or  even  sooner ;  repeat  this  cauterization  as  re- 
quired, till  the  granulating  surface  is  even.  Another  very  good  rem- 
edy is  sprinkling  the  w^ound  with  poAvdered  red  precipitate  of  mercurv 
(hydrar.  oxyd.  rubrum),  which  also  should  be  repeated  daily,  to  im- 
prove the  granulating  surface.  Compression  with  adhesive  plasters 
also  acts  very  well  occasionally.  If  the  granulations  be  exceedinglv 
dense  and  large,  we  often  may  succeed  soonest  by  cutting  some  of 
them  off  with  the  scissors  ;  the  consequent  haemorrhage  is  readily 
arrested  by  applying  charpie.  Where  the  proliferation  is  less,  as- 
tringent lotions,  such  as  decoction  of  oak-bark,  cinchona-bark,  lead- 
water,  etc.,  may  answer  to  excite  the  sluggish  cicatrization. 

2.  By  erethitic  granulations  we  mean  those  characterized  by  great 
pain  on  the  slightest  provocation  ;  they  are  usually  very  proliferant 
granulations,  which  readily  bleed;  it  i§  a  very  rare  condition.  In 
excessive  erethism  of  the  granulations,  they  are  so  sensitive  that  they 
cannot  endvire  the  slightest  touch  or  any  dressing ;  a  less  degree  of  sen- 
sitiveness of  the  granulations  is  not  so  rare.  On  what  it  depends,  is  not 
very  certain ;  granulation  tissue  itself  has  no  nerves  ;  in  most  cases 
touching  it  causes  no  sensation,  only  the  conduction  of  the  pressure  to 
the  subjacent  nerves  causes  sensation.  In  the  above  excessive  sensibil- 
ity, probably  the  ends  of  the  nerves  at  the  floor  of  the  wound  are  degen- 
erated in  a  peculiar  manner ;  perhaps  there  are  miniature  thickenings 
of  the  finest  nerve-ends,  like  those  that  Ave  shall  hereafter  see  on  large 
nerve-trunks.  It  would  be  a  thankworthy  task  to  make  a  careful  ex- 
amination of  this  question.  We  occasionally  observe  similar  condi- 
tions in  the  cicatrices  in  large  nerves,  and  shall  speak  of  this  hereafter. 
For  this  very  painful  sensitiveness,  which  not  only  interferes  with 
!ieaHng,  but  greatly  Avonies   the  patient,  you  may  first  try  soothing 


118  SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS. 

ointments,  almond-oil,  spermaceti-ointment,  or  simple  cataplasms  of 
boiled  oatmeal  or  linseed-meal,  or  warm-water  compresses.  The  nar- 
cotic  compresses  or  cataplasms,  made  with  the  addition  of  belladonna 
or  hyoscyamus-leaves,  are  of  little  benefit.  If  these  applications  do 
not  answer,  do  not  delay  destroying  the  entu-e  granulating  surface,  or 
at  least  the  painful  part,  with  caustic  (nitrate  of  silver,  caustic  potash, 
or  the  hot  iron),  with  the  patient  anaesthetized,  or  else  excising  the 
entire  surface  with  the  knife.  If  the  great  painfulness  be  due  to  hys- 
teria, anaemia,  etc.,  you  Avill  not  attain  much  by  any  local  remedies, 
but  should  try  to  assuage  the  general  irritabihty  by  internal  remedies, 
such  as  valerian,  assafoetida,  iron,  quinine,  warm  baths,  etc. 

3.  In  large  wounds,  especially  in  fistula  granulations,  a  yellow  rind 
sometimes  forms  on  part  of  the  granulation  surface,  which  may  be 
readily  detached,  and  on  careful  examination  is  found  to  consist  of  pus 
cells,  very  firmly  attached  together.  Although  I  have  sometimes 
found  coagulating  filaments  between  the  cells,  they  do  not  always 
occur,  hence  we  must  suppose  that  the  cell-body,  the  protoplasm  itself, 
is  transformed  into  fibrine,  as  occurs  in  true  croup,  and  especially  in  the 
formation  of  fibrinous  deposits  on  serous  membranes.  Here  there  is 
also  a  croup  of  the  granulations.  The  croupous  membrane  reforms 
even  a  few  hours  after  its  removal,  and  this  is  repeated  for  several 
days,  till  it  either  disappears  spontaneously,  or  finally  ceases  on  cau- 
terization of  the  affected  part.  Very  simUar  white  spots  are  occasion- 
ally found  on  larger  granulation  surfaces,  which  are  probably  not 
caused  by  fibrijious  deposits,  but  by  local  obstruction  of  the  blood- 
vessels. Under  peculiar,  unfavorable  conditions,  both  states  may  re- 
sult in  destruction  of  the  granulations,  in  a  true  diphtheria  of  the 
wound,  which  we  shall  hereafter  treat  of  as  hospital  gangrene.  For- 
tunately, however,  it  rarely  goes  on  to  this  disease,  but  the  state  of 
the  wound  improves  again  after  a  time,  and  the  recovery  takes  the 
usual  course. 

If  disease  of  the  granulating  surface  be  accompanied  by  swelling, 
great  pain,  and  fever,  we  have  a  true  acute  inflammation  of  the  wound; 
then  the  raucous  granulation  substance  sometimes  coagulates  through- 
out to  a  fibrinous  mass  ;  the  wound-surface  looks  yellow  and  greasy. 
I  shall  treat  of  the  causes  of  these  secondary  inflammations  under  the 
head  of  contused  wounds.  Usually  the  croupous  inflammation,  which 
has  affected  part  or  the  entire  surface  of  a  Avound,  ends  in  sloughing 
of  the  diseased  granulations,  whereupon  new  granulations  spring  from 
the  depths. 

It  cannot  be  denied  that  the  perfectly  local,  superficial,  and  inter- 
stitial deposit  of  fibrine  strongly  supports  the  view  that  Virchoxt 
has  proposed  for  croupous  processes  generally.     It  was  formerlv  sup 


DISEASES  OF  THE  GRANULATIONS.  119 

posed  that  in  all  inflammatory  croupous  process,  especially  in  the 
ordinary  form  of  acute  inflammation  of  the  lungs  and  pleura,  the 
blood  Avas  over-rich  in  fibrine ;  that  there  was  a  fibrinous  crasis  in  the 
blood,  as  a  result  of  which,  the  excessive  fibrine  escaping  from  the 
capillaries,  coagulates  partly  on,  partly  in,  the  inflamed  surface,  and 
so  led  to  the  formation  of  these  pseudomembranous  deposits.  FeV- 
chow^  on  the  other  hand,  proposed  the  idea  that,  by  the  inflammatory 
process,  the  tissue  may  be  placed  in  a  condition  to  cause  coagulation 
of  the  fibrinous  solution  infiltrating  it.  I  cannot  here  enter  more  par 
ticvdarly  into  the  various  grounds  on  wliich  V^irchow  bases  this  view, 
but  shall  only  call  attention  to  the  fact  that  in  the  case  in  question 
(of  fibrinous  exudation  on  the  granulating  surface),  at  least  there  can 
be  no  rapidly  coming  and  evanescent  fibrous  crasis  of  the  blood ;  but 
CA'identlj'-  it  is  a  local  process  which  may  readily  be  removed  by  local 
remedies.  According  to  the  repeatedly-mentioned  observations  of 
A.  Schmidt,  we  may  infer  that  in  certain  quantitative  and  qualitative 
irritations  of  the  tissue,  more  fibrogenous  tissue  than  usual  escapes 
from  the  capillaries.  Virchoio  had  even  previously  called  attention 
to  the  fact  that,  from  repeated  irritation,  simple  serous  exudation  may 
become  fibrinous  or  croupous.  If  you  apply  a  spanish-fly  blister  to 
the  skin,  a  vesicle  filled  with  serous  fluid  fonns — the  superficial  layer 
being  lifted  from  the  rete  mucosum  by  the  rapidly-forming  serous  exu- 
dation ;  if  we  remove  the  vesicle  and  reapply  the  blister,  in  many 
cases  after  a  few  hours  we  shall  find  the  surface  covered  Avith  a  fibrin- 
ous layer,  which  contains  innumerable  newly-formed  cells ;  indeed,  is 
almost  entirely  composed  of  them.  We  may  attain  the  same  result  bj- 
applying  the  plaster  to  skin  already  inflamed,  or  to  a  young  cicatrix. 

The  treatment  of  croupous  inflammation  of  the  granulations  is 
purely  local ;  we  should  carefully  seek  for  any  causes  of  new  irrita- 
tion, and  try  to  remove  them.  Daily  remove  the  fibrinous  rinds,  and 
cauterize  the  exposed  surface  with  nitrate  of  silver,  or  paint  it  with 
tincture  of  iodine,  and  you  will  soon  see  this  abnormal  state  of  the 
granulating  surface  disappear. 

4.  Besides  the  above  diseases  of  the  granulations,  there  is  occa- 
sionally a  state  of  perfect  relaxation  and  collapse,  in  which  they  pre- 
sent an  even,  red,  smooth,  shiny  surface,  from  which  the  nodular, 
granular  appearance  has  entirely  disappeared,  and,  instead  of  pus,  a 
thin  watery  serum  is  secreted.  This  state  almost  always  occurs  in 
the  granulations  at  the  end  of  life ;  as  already  mentioned,  you  always 
find  it  in  the  cadaver. 

It  is  still  necessary  to  add  something  about  the  cicatrices,  con- 
cerning certain  subsequent  changes  in  them,  their  proliferation  and 
their  shape  in  different  tissues. 


120  SIMPLE   INCISED  WOUNDS   OF   THE   SOFT   PARTS. 

Linear  cicatrices  of  wounds,  that  have  healed  by  first  intention, 
rarely  undergo  subsequent  degeneration.  Large,  broad  cicatrices, 
especially  when  they  lie  immediately  on  the  bone,  often  open  again ; 
the  epidermis,  which  is  tender  at  first,  being  torn  off  by  motion  or  by 
the  least  blow  or  friction,  and  there  is  superficial  atrophy,  an  excoria- 
tion of  the  cicatrix.  Sometimes  the  young  epidermis  is  elevated  like 
a  vesicle,  by  exudation  from  the  vessels  of  the  cicatrix;  there  may 
also  be  some  htemon-hage,  so  that  the  vesicle  will  be  filled  with  bloody 
serum.  Then,  after  removing  the  vesicle,  you  have  an  excoriation,  as 
after  simple  rubbing  off  of  epidermis.  This  opening  of  the  cicatrix, 
if  often  repeated,  may  prove  very  annoying  to  the  patient.  You  pre- 
vent this  most  readily  by  causing  the  patient  to  protect  the  young 
cicatrix  for  a  time  with  wadding  or  a  bandage.  If  the  excoriation 
lias  taken  place,  apply  only  mild  dressings :  oil,  glycerine,  zinc-salve, 
etc.,  or  emplastrura  cerussa.  In  these  cases,  irritating  salves  enlarge 
the  wound,  and  consequently  should  be  avoided. 

If  the  granulating  surface  be  once  perfectly  covered  with  epider- 
mis, as  already  stated,  the  retrogressive  changes  to  solid  connective 
tissue  take  place  in  the  cicatrix,  and  it  atrophies.  But  in  rare  cases 
the  cicatrix  grows  independently,  and  develops  to  a  firm  connective- 
tissue  tumor.  This  is  seen  almost  exclusively  in  small  wounds  that 
have  long  suppurated  and  been  covered  with  spongy  granulations, 
over  which  the  epidermis  formed  exceptionally.  You  know  it  is  the 
custom  to  pierce  the  ear-lobes  of  little  girls,  so  that  they  may  subse- 
quently wear  ear-rings.  This  little  operation  is  done  w'itli  a  coarse 
needle  by  the  mother  or  the  jeweller,  and  a  small  ear-ring  is  at  once 
introduced  through  the  fresh  puncture.  As  a  rule,  this  puncture  soon 
heals — the  ring  preventing  the  closure  of  the  opening.  But  in  other 
cases  there  are  active  inflammation  and  suppuration ;  indeed,  if  the 
suppuration  continue,  the  ring  may  cut  downward  through  the  lobe ; 
granulations  develop  at  the  openings  of  entrance  and  exit ;  finally, 
the  trial  is  given  up,  and  the  ring  removed ;  then  the  opening  often 
heals  quickly.  In  other  cases  the  granulations  cicatrize,  the  cicatrix 
continues  to  grow,  and  on  both  sides  of  the  lobe  of  the  ear  small 
connective-tissue  tumors,  small  fibroids,  form.  These  look  like  a  thick 
shirt-button  drawn  through  the  hole  of  the  ear,  and  they  grow  inde- 
pendently like  a  tumor.  If  you  examine  these  tumors,  on  section 
you  find  them  of  pure  white  tendinous  appearance,  like  the  cicatrix 
itself.  Microscopically  the  tissue  is  found  to  consist  of  connective 
tissue  with  numerous  cells ;  it  is  simply  a  prohferation,  an  hypertrophy 
of  the  cicatrix.  I  have  seen  this  twice  in  the  ear ;  another  case  is 
mentioned  by  Dleffenhach  in  his  operative  surgery.  I  once  saw 
similar  tumors  on  the  back  of  the  neck,  where  they  had  formed  at  the 


\ 


CHANGES  IX  CICATRICES. 


121 


cpeaings  made  for  a  seton;  they  were  about  tlie  size  of  a  horse- 
chestnut.  They  should  be  carefully  removed  with  the  knife,  and  any 
subsequent  granulations  kept  in  subjection  by  nitrate  of  silver. 

[The  translator  has  seen  the  above  tumors  on  the  lobe  of  the  ear 
several  times ;  in  all  but  two  instances  they  occurred  in  mulatto 
females ;  in  one  case  the  tumor  had  returned  after  a  previous  re- 
moval.] 

In  the  above  description  of  the  formation  of  granulations  and  cica- 
trices, for  the  sake  of  simpHcity  we  have  only  referred  to  the  process 
as  it  is  found  in  connective  tissue,  but  must  now  speak  of  it  as  it 
occurs  in  cicatrization  of  other  tissues. 

The  cicatrix  in  muscle  is  at  first  almost  entirely  connective  tissue  j 

Fig.  is. 


ff.'/ 


Cicatrix  from  the  tipper  lip  of  a  dog.  a,  connective  tissue  of  the  cicatrix.  The  divided  mnscnlar 
tibie?  aro  here  atrophied  for  a  short  disftauce,  and  terminate  iu  a  conical  shape.  Magni- 
fied 300  diameters. 


in  the  ends  of  the  muscular  fibres  there  is  at  first  destruction,  then  at 
a  certain  boundary  a  collection  of  nuclei ;  then  there  is  rounding  off 
of  the  fibres,  sometimes  club-shaped,  sometimes  of  more  conical  form, 
and  the  stumps  of  the  muscular  fibres  unite  with  the  connective  tissue 
of  the  cicatrix  just  as  they  do  with  the  tendons  ;  the  muscle  cicatrix 
becomes  an  inscriptio  tendinea.  I  myself  have  only  observed  them  in 
wounds  of  muscle  that  had  healed  by  first  intention,  and  have  never 
there  seen  any  thing  that  I  could  decide  was  a  new  formation  of  mus- 
cular tissue.  In  suppurating  ends  of  muscle,  0.  Weber  has  witnessed  a 
slight  formation  of  new  muscle  ;  this  appears  to  occur  chiefly  in  for^ 
iaiation  of  granulations  on  muscle  and  in  certain  tumors. 

Weber  is  of  the  opinion  that  young  muscular  fibres  typically  form 


122 


SIMPLE   INCISED   WOUNDS   OF   THE   SOFT   PARTS. 


from  the  cells  of  old  ones,  but  considers  it  impossible  to  prove  that  no 
muscular  cells  originate  from  other  young  ceUs.  As  a  result  of  his 
examination  of  old  muscular  cicatrices,  he  also  maintains  that  the  re- 
generation continues  a  long  tune,  and  in  most  cases  is  more  complete 
than  is  generally  supposed.     3faslowsky  has  affirmed  the   aaetamor- 


Fia.  19, 


Ends  of  divided  mnscnlar  fibres  from  the  biceps  mnscle  of  a  rabbit  eight  days  after  the  injury; 
abc,  old  muscular  fibres;  a,  the  contractile  substance  rolled  up  and  balled  together;  the 
same  way  in  the  bundle  above  d  ;  the  same  with  the  sarcolemma  drawn  out  to  a  point ;  c, 
into  the  pointed  comet-shaped  sarcolemma  tube  extends  a  series  of  young  muscular  nuclei, 
between  which  there  is  very  delicate  transversly  striated  substance ;  «,  the  same  with 
young,  free  muscle-ceils ;  /,  two  young  ribbon-like  muscular  filaments ;  g,  the  same  of  vari- 
ous size  isolated     Magnified  450  diameters ;  after  0.  Weber. 


phosis  of  wandering  cells  to  muscle-cells  ;  but  I  consider  the  cinnabar 
method  employed  by  him  as  insufficient  to  prove  this  assertion.  [Cin- 
nabar or  vermihon  injected  into  the  blood  is  taken  up  by  white  cor- 
puscles, and  may  afterward  be  discovered  on  inflamed  tissue.] 

Gussenhauer  has  shown  that,  after  injury,  the  muscular  filaments 
usually  break  down  into  flakes,  and  then  new  young  muscle-cells 
form,  after  the  type  of  embryonal  development,  from  the  cells  con- 
tained in  the  old  muscle-filaments ;  the  amount  of  the  new  formation 
depends  on  the  quality  and  duration  of  the  irritation. 

If  a  nerve  be  divided,  its  ends  separate,  from  their  elasticity,  they 
swell  slightly,  and  subsequently  unite  by  development  of  a  new  forma- 
tion of  true  nerve-tissue,  so  that  the  nerve  is  again  capable  of  conduo- 


CICATRICES   L\   MUSCLES   AND   NERVES. 


123 


tion  through  the  cicatrix.  In  large  superficial  cicatrices,  new  nerves 
develop  ;  when  you  have  excised  portions  of  skin  and  have  brought  to- 
gether and  united  parts  lying  at  a  distance,  new  nerves  grow  through 
the  cicatrix  and  perfect  power  of  conduction  comes  after  a  time,  as 
may  be  often  observed  in  plastic  operations.     These  facts  are  very 

Fig.  20. 


Eegenerative  processes  in  transversely -striated  muscular  fibres  after  iniury.    Magnified  about  500, 

after  Gussenbauer. 

remarkable,  and  physiologically  are  still  entirely  inexplicable.  Just 
think  how  wonderful  that  these  nerve-filaments,  sensory  and  motor, 
should  find  each  other  in  the  new  adhesion,  and  that  even,  as  we  must 
suppose,  the  stumps  of  the  primitive  fibres  should  unite  as  they  had 
been  imited,  so  that  correct  conduction  and  localization  might  result 
as  they  actually  do  !  We  cannot  here  go  more  exactly  into  this  sub- 
ject. I  will  only  mention  that  the  more  minute  process,  which  has 
been  very  carefully  followed  by  Schiff,  Hjelt,  and  others,  is  generally 
as  follows :  first,  in  the  stump  of  the  nerve  there  is  a  destruction  of 
the  nerve-sheath,  possibly  also  of  the  axis  cylinder  to  a  certain  extent ; 
at  the  same  time  in  the  neurilemma  there  is  a  collection  of  cells, 
which  proceeds  to  the  development  of  spindle-shaped  cells  in  the  sub- 
stance lying  between  the  ends  of  the  nerve,  and  extending  into  the 


124 


SIMPLE  INCISED   WOUNDS   OF   THE   SOFT   PARTS. 


stump.  From  these  cells,  just  as  in  the  embryo  during  intra-uterine 
life,  new nerve-fibrillae  develop  upward  and  downward;  the  filaments, 
which  are  at  first  very  pale,  subsequently  acquire  a  sheath,  and  then 
cannot  be  disting-uished  from  ordinary  nerve-filaments. 

The    most    recent 

Fig  22. 


Fig.  21. 


Regeneration  of  nerves.  Fig.  21,  from  a  rabbit  fifteen  days  after 
division  ;  younsr  spindle-cells  in  the  end  of  the  nerve  developed 
from  the  connective  tissue  and  intimately  connected  with  the 
neurilemma.  Fig.  22,  from  the  frotr  ten  weeks  after  division; 
development  of  young  nerve-cells  from  the  spindle-cells.  Mag- 
nified 300  diameters,  after  Ujelt. 


investigations  as  to 
the  significance  of 
wandering  cells  in 
new  formation  of  tis- 
sue, as  "well  as  the 
special  studies  over 
the  formation  of 
nerves  in  portions  of 
tadpoles'  tails  regen- 
erated after  injury, 
have  made  me  doubt 
the  former  view,  that 
young  regenerated 
nerve-filaments  were 
composed  of  spindle- 
cells.  It  seems  to  me 
much  more  probable 
that  the  divided  axis- 
cylinders  grow  out  in- 
to young  nerve-filaments,  and  that  the  elongated  spindle-cells,  which 
undoubtedly  exist  in  the  nerve-callus  in  certain  stages,  either  belong 
to  the  connective  tissue  of  the  neurilemma  or  are  detached  portions 
of  young  nerve-filaments  containing  nuclei. 

The  last  investigations  of  Neumann  and  Eichhorst  confirm  pre- 
vious ones  in  regard  to  the  immediate  results  of  division,  but  show 
that  the  young  nerve-filaments  grow  directly  from  the  axis-cylinder, 
as  well  from  the  central  as  from  the  distal  part,  meet  together,  and 
blend,  as  the  offshoots  from  a  capillary  wall  sink  into  the  wall  of 
another  vessel,  and  so  may  form  a  communicating  canal  between  two 
vessels  {Arnold).  The  process  in  the  wounded  nerve  corresponds 
most  beautifully  with  that  in  wounded  muscle.  In  the  muscular  as 
in  the  nervous  filament  several  young  filaments  sprout  from  one 
primitive  filament  (a,  Fig.  22  a  ;  compare  Fig.  20). 

So  it  is  shown  that  muscles,  vessels,  nerves,  and  epithelium  are 
not  regenerated  from  proliferating  connective-tissue  cells  or  wan- 
dering cells,  but  from  throwing  out  offshoots  from  their  tissue,  or 
from  cells  derived  from  the  protoplasm  of  their  tissue.  It  is  very 
probable  that  connective-tissue  cells  also,  especially  those  still  con- 


CICATRICES  IN   MUSCLES   AND   NERVES. 


121 


taining  protoplasm,  send  out  offshoots  at  the  wounded  part  in  which 
nuclei  subsequently  form,  as  is.  done  in  the  nerves  of  the  tadpole's 
tail.  This  point  should  be  investigated  again  ;  till  then  we  may  re- 
gard wandering  cells  as  the  source  of  the  young  regenerated  tissue. 
Since  Schwann's  teaching  about  the  development  of  tissue  from 
cells,  we  are  so  convinced  that  every  new  tissue  proceeds  from  young 
cells,  that  the  announcement  of  independent  growth  of  a  perfect 
tissue  without  intervention  of  cells  finds  little  credit ;  and  the  increase 


Nerve  of  a  rabbit:  a,  seventeen  davs  after  division;  b.  fifty  days;  c,  frog's  nerve,  thirty  days.    Mag- 
nified about  600.    After  JSichhorst. 

of  cells  by  offshoots,  with  subsequent  development  of  nuclei  in  these 
offshoots,  is  a  procedure  that  histologists  have  long  kept  in  the 
background,  substituting  for  it  cell-division,  although  botanists  have 
ascribed  a  very  prominent  role  to  this  mode  of  development  in 
plants.  From  the  latest  published  observations  we  see  that  the 
capillary  walls,  the  axis-cylinder  of  nerves,  and  the  contents  of  mus- 
cular filaments  possess  this  capacity  for  outgrowth  without  direct 
participation  of  new  cells,  MoJcitanslcy  ascribed  to  connective  tis- 
sue the  capacity  for  independent  outgrowth. 

Tn  the  human  being  the  regeneration  of  nerves  only  takes  place 
within  certain  limits,  which,  it  is  true,  cannot  be  very  accurately  de- 
fined. The  complete  regeneration  of  large  nerve-trunks,  as  of  the 
sciatic  or  median  nerves,  does  not  occur;  nor  does  it  take  place  after 
excision  of  large  portions  of  nerve,  ii  the  ends  remain,  say  three  or 
four  lines  apart.  Very  accurate  apposition  of  the  ends  of  the  nerve 
is  necessary,  for  apparently  the  transformation  of  the  newly-formed 
intermediate  substance  to  nerve-substance  can  only  take  place  by 
means  of  the  nerve-stump,  although  there  are  different  opinions  about 


126 


SIMPLE  INCISED  WOUNDS  OF  THE  SOFT  PARTS. 


the  mode  of  this  process  ;  we  shall  see  similar  conditions  in  the  heal- 
ing of  broken  bones,  where  bony  union  only  follows  accurate  coapta- 
tion of  the  fragments.  Now,  how  is  it  in  this  respect  with  brain  and 
sjnnal  tissue?  In  the  human  being  there  is  no  regeneration  here 
after  injury,  or  after  loss  of  substance  from  idiopathic  inflammation,  or 
at  least  not  sufficient  to  restore  the  power  of  conduction.  In  animals, 
indeed,  as  Broim-Sequard  has  shown  in  pigeons,  after  dividing  the 
spinal  marrow,  there  may  be  regeneration  with  disappearance  of  the 
paralysis,  which  has  of  course  occurred  in  all  parts  below  the  point  of 
division.  Unfortunately,  this  power  of  regeneration  of  nerves  decreases 
in  proportion  to  the  higher  development  of  the  vertebrate  animals, 
and  it  is  least  in  man.  As  is  known,  in  young  salamanders  whole 
extremities  grow  again  when  they  have  been  amputated.  "What  a 
pity  this  is  not  so  in  man  !  However,  as  regards  the  nerves,  Nature 
occasionally  seems  to  make  a  fruitless  attemjDt  at  regeneration  ;  for 
quite  often  the  nerve-ends  in  amputation-stumps,  instead  of  simply 
cicatrizing,  develop  to  club-shaped  nodules,  which  are  occasionally  ex- 
cessively painful,  and  require  subsequent  excision.  These  nodules  on 
the  nerves  consist  of  an  entanglement  of  the  primitive  nerve-filaments, 
which  develop  from  the  stump  of  the  nerve  as  if  they  would  grow  to 
meet  opposite  nerve-ends.  The  cicatrices  in  the  continuity  of  nerves 
also  are  sometimes  nodular  from  the  formation  of  convoluted  primitive 
filaments.  Such  small  nerve-tumors  (true  neuromata)  are  occasion* 
ally  excessively  painful,  and  must  be  removed  with  the  knife.  But 
there  are  also  traumatic  neuromata,  which  are  not  at  all  painful,  as  I 
have  seen  in  old  amputation-stumps.  In  general,  these  proliferations 
of  nerve-cicatrices  are  to  be  compared  with  the  previously-mentioned 
hypertrophy  of  connective  -  tissue  cicatrices,  and  with  proliferating 
bone,  which,  although  rarely,  is  formed  in  great  excess  in  the  heahng 
of  broken  bones. 

The  process  of  heahng  after  injury  of  great  vessels,  especially  of 
arterial  trunks,  has  been  carefully  determined  by  experiment.  If  a 
large  artery  be  ligated  in  an  amputation  or  for  disease  in  its  continu- 
ity, as  the  ligature  is  drawn  tight,  the  tunica  intima  is  ruptured,  and 
the  tunica  muscularis  and  adventitia  are  so  constricted  that  their  inner 
surfaces  folded  up  lie  in  exact  apposition.  You  may  satisfy  yourselves 
of  the  frequent  although  not  necessarily  universal  rupture  of  the  in- 
ternal tunic,  by  hgating  a  large  arterial  trunk  in  the  cadaver,  for  you 
not  unfrequently  experience  a  slight  grating  or  crackling  under  the 
finger  when  tightening  the  ligature ;  you  may  also  see  it  on  cutting 
open  a  Hgated  artery  after  detachment  of  the  ligature.  From  the 
point  of  hgation  to  the  next  branch  leaving  the  artery,  both  at  the  cen- 
tral and  periplieral  ends,  the  calibre  of  the  vessel  fills  with  coagulated 


FORMATION   OF   THROMBUS. 


127 


PlQ.  23. 


Nalalar  nPi't'e-termiDatioTiP  in  an  old  ampntation-Ptnmp  of  tlie  arm.  Krom  a  preparation  )d 
the  Anatomical  Museum  at  Buuu.  Copied  after  Frorlep,  "  Surgical  Copperplates."  Bd.  L, 
Taf.  113. 


blood,  the  so-called  thrombus  (from  6  ■Bpofxiiog,  the  blood-clot).  The 
enveloping  ligature  kills  the  enclosed  tissue,  which  gradually  breaks 
down  into  pus,  and  when  this  process  is  completed  the  ligature  falls, 
or,  as  we  technically  express  it,  "  the  ligature  has  cut  through,"  "  comes 
away."  When  this  has  taken  place,  the  calibre  of  the  artery  must  be 
permanently  and  certainly  closed,  or  there  will  at  once  be  another 
haemorrhage.  Under  unfavorable  circumstances  it  may  certainly  happen, 
in  small  as  well  as  in  arteries  of  medium  or  large  size,  that  the  ligature 
cuts  through  too  soon,  and  then  dangerous,  sudden  secondary  haemor- 
rhage occurs.  We  may  foresee  this  if  the  wall  of  the  artery  was  dis- 
eased ;  often  calcified  arteries  cannot  be  ligated,  as  the  ligature  does 
not  compress  them  or  cuts  through  them  at  once  ;  sometimes  the  ar- 
tery is  softened  (as,  for  instance,  when  part  of  its  course  has  been 
through  the  wall  of  a  large  abscess)  so  that  on  ligation  the  ligature 
cuts  through  and  must  be  applied  farther  up.  But  unfortunately,  in 
perfectly  healthy  subjects,  as  I  found  in  the  last  war,  haemorrhages 
too  often  occur  from  the  point  of  ligation  of  large  arteries,  where 
carefully-applied  ligatures  cut  through  before  the  organic  closure  was 
firm  enough  to  resist  the  current  of  blood ;  this  greatly  impairs  the 
value  of  such  operations,  which  are  often  temporarily  necessary  to 
save  tlie  patient's  life. 


123 


SIMPLE  IXCISED  WOUNDS   OF   THE   SOFT   PARTS. 


Artery  li^ated  in  the 
continuity.  Throm- 
bus ;  after  Froriep. 


Passing  now  to  the  consideration  of  what  has  taken  place  in  the 
end  of  the%essel  from  the  coagulation  of  the  blood  till  the  firm  closure, 
experiments  on  animals  and  accidental  observations  ^j^  g^ 

on  man  have  given  the  following :  the  blood-clot  at 
first  lying  loose  in  the  vessel  gradually  becomes  more 
firmly  attached  to  the  wall  of  the  vessel,  and  con- 
stantly grows  harder,  but  still  remains  red  for  a  long 
time  ;  it  does  not  lose  its  color  for  weeks  or  months, 
and  then  does  so  first  in  the  centre,  so  that  the  rest 
of  it  still  retains  a  slight  yellowish  tinge.  After  the 
detachment  of  the  hgature,  the  thrombus  is  so  hard 
and  so  firmly  attached  to  the  walls  of  the  vessel 
that  the  calibre  is  entirely  closed.  The  preparation 
(Fig.  24)  shows  you  the  thrombus  formation  in  an 
artery  after  ligation  in  the  continuity ;  the  lower 
thrombus  reaches  to  the  point  of  departure  of  the 
first  branch,  the  upper  one  not  so  far ;  the  former  is 
the  rule  as  laid  down  in  most  books,  the  latter  is  a 
not  uncommon  exception.  Plugging  of  the  artery 
hy  a  blood-clot,  which  becomes  firm,  is,  however,  only 
a  provisional  state,  for  the  thrombus  does  not  remain  so  for  all  future 
time,  but  the  cicatricial  tissue  shrinks  and  atrophies ;  this  takes  place 
in  the  course  of  months  and  years,  at  which  time  the  closure  of  the 
artery  at  the  point  of  division  has  become  solid  by  adhesion  of  the 
walls  of  the  vessel.  If  you  examine  such  an  artery  a  few  months  after 
the  ligation,  you  find  nothing  of  the  thrombus ;  but  the  artery  termi- 
nates in  a  conical  point  of  cicatricial  connective  tissue. 

The  above  changes,  which  we  may  follow  with  the  naked  eye, 
show  that  in  the  blood-clot  there  is  a  change  which  essentially  consists 
in  its  increasing  firmness  and  coherence  to  the  wall  of  the  vessel ;  we 
shall  now  study  w^th  the  microscope  on  what  this  transformation  of 
the  blood-clot  depends.  If  you  examine  the  recent  blood-clot,  you 
find  it  to  consist  of  red  blood-corpuscles,  a  few  colorless  blood-cells, 
and  of  fine  filaments  and  coagulated  fibrine,  arranged  in  irregular  net- 
work. If  you  take  a  thrombus  two  days  after  the  ligation  of  a  small 
or  medium-sized  artery,  it  is  firmer  than  at  first,  and  is  broken  up  with 
difficulty ;  the  red  blood-cells  are  little  changed,  the  white  ones  are 
greatly  increased;  they  have  sometimes  two  and  three  nuclei  as  pre- 
viously, sometimes  single  pale,  oval  nuclei  with  nucleoli;  some  of 
these  cells  are  almost  double  the  size  of  white  blood-cells.  The  fine 
filaments  of  the  fibrine  are  united  to  an  almost  homogeneous  mass, 
which  is  difficult  of  di^dsion.  If  you  again  examine  a  thrombus  six 
days  old,  the  red  blood-cells  have  almost  disappeared,  the  fibrine  is 


FORMATION   OF   THROMBUS.  129 

more  firm  and  homogeneous,  and  even  more  difficult  to  separate  than 
previously;  a  large  number  of  spindle-shaped  cells  with  oval  nuclei, 
showing  distinct  divisions,  appear.  From  the  above,  it  appears 
that  even  quite  early  a  number  of  living  cells  appear  in  the  blood- 
clot,  whose  further  development  will  be  seen  from  what  follows. 
Since  we  obtaiji  a  more  accurate  understanding  of  the  changes  in  the 
thrombus  and  its  relation  to  the  arterial  walls,  by  making  transverse 
sections  of  the  thrombosed  artery,  we  shall  proceed  to  do  this. 

This  preparation  shows  a  transverse  section  of  a  recent  throm- 
bus in  a  small  artery;  within,  the  delicate  mosaic  formed  by  the  crowded 

red  blood-corpuscles,  among  them  a 
Fig.  25.  few    round  white  blood-cells   (which 

have  been  rendered  visible  by  car- 
mine) ;  next  comes  the  tunica  intima, 
laid  together  in  regular  folds,  in 
which  the  blood-clot  clings ;  then  the 
tunica  muscularis ;  then  the  tunica 
adventitia,  with  the  net-work  of  elas- 
tic fibres  ;  to  the  right  some  adherent 
loose  connective  tissue.  The  next 
preparation  (Fig.  26)  is  the  transverse 
section  of  a  human  artery,  closed  with 
a  thrombus  for  six  days ;  we  see  no 
'"''"''''^^S'^o^I^^!''^'''-      red  blood-cells;    the  white  ones  are 

greatly  increased,  mostly  round ;  but, 
in  the  tunica  adventitia  and  surrounding  connective  tissue,  there  has 
already  been  some  cell  infiltration.  If  we  now  examine  a  ten-day-old 
thrombus  from  a  large  muscular  artery  of  the  thigh  of  a  man  (Fig.  27, 
a),  we  find  it  already  containing  numerous  spindle-cells,  which  are  partly 
arranged  in  stride  (subsequently  vessels)  ;  the  intercellular  substance 
is  filamentary,  here  rendered  transparent  by  acetic  acid.  Finally,  there 
is  also  formation  of  blood-vessels  in  the  organized  thrombus,  as  you 
see  in  the  following  preparations  (Figs.  28  and  29). 

It  has  been  established,  by  the  investigations  of  0.  Weber,  that 
the  vessels  of  the  thrombus  communicate  partly  with  the  calibre  of 
the  thrombosed  vessel,  partly  with  its  vasa  vasorum. 

The  process  of  healing  in  transversely-divided  veins  appears  at 
the  first  glance  to  be  much  simpler  than  in  the  arteries ;  even  in  the 
'arge  veins  of  the  extremities,  the  divided  ends  fall  together,  and  ap- 
pear to  heal  at  once,  as  soon  as  the  blood  has  been  obstructed  at  the 
next  valve  above  ;  at  these  valves  clots  form,  and  they  are  often  much 
larger  than  is  desirable ;  this  formation  of  clots  extending  toward  the 
heart  will  hereafter  occupy  our  earnest  attention.  But  I  have  of  late 
10 


130 


SIMPLE  INCISED   WOUNDS   OF   THE   SOFT   PARTS. 


observed  that  the  tunica  intima  of  the  divided  vein  does  not  by  any 
means  so  fold  together  and  adhere,  but  that  here  also  there  is  a  clot, 
althouo-h  a  small  one,  which  is  organized  like  the  arterial  thrombus. 


Fio.  26. 


Traneverse  section  of  a  thrombus  six  days  old.    300  diametera. 


Fig.  27. 


a 


Cec-dRy-oid  thrombus,   a.  Orjxanized  thrombus ;  b.  Tunica  intiraa ;  c.  Tunica  muacnlariB ;  d. 
Tunica  adveutitia.    300  diameters. 


FORMATION    OF   THROMBUS. 


131 


If  jou  draw  conclusions  from  these  preparations,  presented  in  such 
a  fragmentary  way,  it  appears  that  in  the  clotted  blood  there  is  a  cel- 
lular infiltration,  Avhich  here  leads  to  development  of  connective  tissue ; 
in  short,  that  the  thrombus  becomes  organized.  The  thrombus  is  not 
a  permanent  tissue,  but  gradually  disappears  again,  or,  at  least,  is  re- 
duced to  a  minimum,  a  fate  which  it  shares  with  many  new  formations 
resultino:  from  inflammation. 


Completely-orgauized  thrombus  in  the  human  arteria  tibialis  postica.  a.  Thrombus  with  ves- 
sel*, perfectly  uuiti^i  with  the  innermost  layer  of  the  intima;  6,  the  lamellae  of  the  tunica 
intima;  c,  the  tunica  muscularis,  traversed  by  numerous  connective  tissue  and  elastic  fila- 
ments ;  d.  Tunica  adventitia.    Magnified  300  "diameters.    After  R'mdjieisch, 

Peculiar  reasons  caused  me  to  investigate  more  accurately  the  or- 
ganization of  the  thrombus.  The  importance  of  this  process  is  rather 
extensive ;  a  point  on  which  you  cannot  at  present  judge  well,  but 
will  hereafter  be  in  a  position  to  estimate  fully,  when  we  come  to 
treat  of  diseases  of  the  vessels. 

From  my  investigations  up  to  the  present  time,  I  do  not  think  I 
dare  retract  the  assertion  that  coagulated  fibrine  may,  by  aid  of  cells, 
be  transformed  into  connective-tissue  intercellular  substance,  although 
I  cannot  decide  whether  this  be  due  to  true  metamorphosis,  or  to  a 
gradual  substitution  of  cell  protoplasm  for  disappearing  fibrine.  Some 
have  attempted  to  refer  the  origin  of  the  cells,  which  appear  in  con- 


132  SIMPLE  INCISED  WOUNDS  OF   THE   SOFT  PARTS. 

stantly-increasing  numbers  in  the  thrombus, to  the  wall  of  the  vessel; 
the  arteries,  as  well  as  the  veins,  are  coated  with  a  lining  of  epithe- 
lium which  to  some  extent  represents  the  innermost  lamella  of  the 
tunica  intinia.     These  epithelial  cells  and  the  nuclei  ot  the  striated 

Fig.  29. 


L<;ngituclinal  section  of  the  lig&ted  ei;d  ol'  the  emra!  artery  of  a  dog,  fifty  days  after  ligation  • 
the  thrombus  is  injected;  a  a.  tanica  iutima  aud  media ;  h  b,  tunica  adventitia.  Magnified 
40  diameters. 


lamellae  of  the  intima  have  been  claimed  a  priori  by  some  authors,  so 
that  they  could  let  new  cells  be  formed  from  them,  and  grow  into  the 
thrombus ;  in  his  last  work,  Thiersch  also  inclines  to  this  view.  I 
acknowledge  that  I  myself  formerl}^  strongly  combated  the  supposi- 
tion that  the  blood  could  of  itself  become  organized  to  connective 
tissue  with  vessels ;  but  from  examinations  of  transverse  sections  of 
thrombosed  arteries,  I  am  satisfied  of  its  correctness.  After  having 
abandoned  the  idea  of  proliferation  of  stable  tissue-cells  in  inflamma- 
tion, we  can  no  longer  talk  of  a  proliferation  of  the  intima  in  the  old 
sense.  But  whence  come,  then,  these  newly-formed  cells  ?  I  have  no 
doubt  that  they  originate  from  the  white  blood-cells,  wliich  have  been 


FORMATION  OF  THROMBUS. 

Fig.  30. 

a       ^ 


133 


d 


Cortion  of  a  transverse  gectioti  of  a  human  femoral  vein,  with  an  organized  vascular  thrombufe, 
18  days  after  amputation  of  the  thigh ;  a  a,  Tunica  intima  j  h  b,  media ;  c  c,  adventitia  ;  d  d, 
envefopiug  celhdar  tissue ;  T/i,  organized  thrombus  with  vessels ;  the  layering  of  the 
fibrine  is  still  distinctly  visible  in  the  periphery  of  the  thrombus.  Magnified  100  diametera. 

partly  enclosed  in  tlie  thrombus,  partly  may  have  wandered  into  it, 
according  to  the  observations  of  V.  Recklinghausen  and  Buhnoff. 
As  regards  the  red  blood-cells,  it  seems  that  they  gradually  unite  with 
the  coagulated  fibrine,  lose  their  shape,  become  intercellular  substance, 
and  lose  their  coloring  matter,  which  is  separated  as  granules  or  crys- 
tals of  hematoidin.  Little  as  we  know  whence  blood-cells  come,  and 
whither  they  go,  still  it  is  certain  that  the  white  cells  enter  the  blood 
from  the  lymphatic  vessels,  and  that  they  enter  the  latter  from  the 
lymphatic  glands  or  connective  tissue  elsewhere  ;  they  are  cells  that 
originate  directly  from  connective-tissue  cells,  or  from  a  protoplasm 
analogous  to  connective  tissue.  Are  these  cells  still  viable  when  en- 
closed in  a  blood-clot  ?  After  coming  to  rest  here,  can  they  transform 
themselves  to  tissue  ?  It  is  impossible  to  affirm  or  deny  these 
questions  absolutely  :  since  Buhnoff  has  shown  that  wandering  cells 
enter  the  thrombus,  and  may  there  continue  their  movements,  there 
is  no  necessity  for  supposing  that  the  white  blood-cells  (which  are 
identical  with  wandering  cells)  enclosed  in  the  thrombus,  on  coagula- 


134  SIMPLE  INCISED   WOFxXDS   OF   THE   SOFT   PARTS. 

tion,  no  longer  move,  and  cannot  be  transformed  into  tissue.  Hith- 
erto'there  have  been  no  investigations  as  to  whether  wandering  cells 
pass  through  the  walls  of  arteries  as  readily  as  through  those  of  veins, 
as  Buhnoff's  investigations  only  refer  to  venous  thrombi.  Some  of 
my  investigations  in  this  direction  showed  me  that  minute  cinnabar 
o-ranules  passed  through  the  carotid  of  a  dog  into  the  thrombus,  but 
I  could  not  satisfy  myself  that  they  were  replaced  by  wandering  cells. 
So  at  present  it  is  uncertain  w^hence  the  numerous  wandering  cells  in 
an  organizing  arterial  thrombus  originate,  and  how  they  enter  there. 
Tschausoff,  in  a  very  carefully-studied  work  that  has  lately  appeared, 
calls  attention  to  the  fact  that  a  great  portion  of  large  thrombi  are 
destroyed  by  disintegration.  This  is  very  true,  but  he  goes  too  far 
when  he  entirely  denies  the  provisional  organization  of  the  thrombus, 
and  supposes  that  the  disintegration  of  the  clot  is  immediately  fol- 
lowed by  the  adhesion  of  the  walls  of  the  vessel,  to  which  I  have 
called  attention  as  the  definite  termination  of  the  whole  process. 

As  I  have  already  stated,  peculiarly  favorable  conditions  are  re^ 
quisite  for  the  blood-clot  to  become  organized.  It  is  an  absolute  law 
in  the  human  organism,  that  non-vascular  tissues,  which  are  nourished 
by  means  of  cells  alone,  have  no  great  extent ;  the  articular  cartilages, 
the  cornea,  the  tunica  intima  of  these  vessels,  the  tissues,  are  all  in  thin 
layers ;  in  other  words,  the  cells  of  the  human  body  cannot,  like  those  of 
plants,  carry  nutrient  fluid  to  any  given  distance,  but  are  limited  in 
their  conductive  power ;  at  certain  distances  new  blood-vessels  must 
appear,  to  supply  and  carry  off  the  nutrient  fluid.  The  blood-clot, 
consisting  of  cells  with  coagulated  fibrine,  is  at  first  a  non-vascula' 
cellular  tissue,  which  can  only  maintain  its  existence  in  thin  layers. 
This  appears  from  observations,  which  we  shall  hereafter  often  have 
occasion  to  mention  ;  namely,  that  large  blood-clots  are  not  organized 
at  all,  or  only  in  their  peripheral  layers,  while  they  disintegrate  in  the 
centre.  From  this  it  appears  that,  in  healing  by  the  first  intention,  a 
small  amount  of  blood  lying  between  the  edges  of  the  wound  does  no 
harm,  while  a  larger  amount  interferes  with  healing,  or  prevents  it 
altogether.  You  will  soon  be  able  to  verify  this  observation  in  the 
clinic. 

The  formation  and  organization  of  the  thrombus  have  engaged 
the  attention  of  surgeons  and  anatomists  since  the  time  of  tTohn 
Hunter  and  even  yet  they  are  not  fully  understood.  We  must  con- 
sider them  here  on  account  of  their  general  histogenetic  interest,  al- 
though of  late  it  is  doubtful  whether  thrombi  are  practically  as  im- 
portant for  the  results  of  ligation  as  was  formerly  supposed.  Even 
Porta  called  attention  to  the  fact  that  the  quick  adhesion  and  union 
of  the  tissue  around  the  ligated  artery  was  as  important  as  organiza- 
tion of  the  thrombus.     Surgeons  have  kept  this  point  well  in  view 


CIRCULATIOX  AFTER   LIGATIOX. 


135 


always  striving,  by  most  carefully  operating  and  attending  to  the 
wound,  to  attain  healing  by  the  first  intention.  But  it  was  the  suc- 
cess of  acupressure  which  first  showed  clearly  that  the  adhesion  of 
the  tissues  by  coagulable  exudation  even  in  forty-eight  hours  is 
enough  to  keep  securely  the  compressed  or  twisted  artery,  even 
when  it  is  the  size  of  the  femoral.  Although  Kocher  has  shoAvn  that, 
even  after  acupressure,  thrombi  occur  in  arteries,  yet  they  are  too 
small  to  check  bleeding  in  a  large  artery  within  forty-eight  hours. 
Hence,  even  from  this  point  of  view,  attempts  to  replace  the  ligature 
by  other  methods,  which  leave  no  threads  in  the  wound  but  permit 
its  entire  closure  by  first  intention,  should  be  encouraged  without 
denying  in  any  way  the  extraordinary  advantages  of  the  ligature. 


Let  us  now  look  at  the  fate  of  the  circulation  after  Ugatinga  large 
artery  in  the  continuity.  Suppose  that,  for  a  haemorrhage  in  the  leg, 
the  femoral  artery  has  been  ligated  ;  how  does  the  blood  now  reach 
the  leg  ?  how  will  the  circulation  go  on  ?  Just  as  on  closure  of  capil- 
lary districts,  under  increased  pressure,  the  blood  presses  through  the 
next  permeable  vessels,  which  are  thereby  dilated ;  the  same  thing 
occurs  on  closure  of  small  or  medium-sized  arteries.  Under  increased 
pressure,  the  blood  flows  through  the  branches  close  above  the 
thrombus,  and  from  the  numerous  arterial  anastomoses,  both  in  the 

Pis.  32. 


Fia.  31. 


Carotid  artery  of  a  rabbit, 
injected  6  weeks  after 
ligation.    After  Fmta 


Carotid  artery  of  a  aont.  injected 
33  months  after  li^'aliou  Af- 
ter Porta. 


136 


SIMPLE   INCISED   WOUXDS   OF  THE   SOFT   PARTS. 


Fio.  83. 


long  axis  and  various  transverse  axes  of  the  limb,  reaches  other  arteries, 
tlirough  which  it  soon  again  streams  into  tlie  peripheral  end  of  the  hgat- 
ea  vessel.  An  arterial  collateral  circulation  is  established  to  the  side  of 
the  ligated  and  thrombosed  portion  of  the  arterial  trunk.  Without  this, 
the  part  of  the  body  lying  below  this  point  would  not  receive  suffi- 
cient blood  and  would  die ;  it  would  dry  up  or  putrefy.  Fortunately, 
arterial  anastomoses  are  so  free  that,  even  after  ligation  of  a  large 
artery,  like  the  axillary  or  femoral,  such  a  case  is  not  apt  to  occur ;  in 
diseased  arteries,  however,  which  do  not  distend  sufficiently,  mortifi 
cation  of  the  affected  extremity  may  occur.  The  modes  in  which 
these  new  vascular  connections  form  vary  greatly.  Years  ago,  Porta 
made  very  jDrofound  researches  on  this  point,  and  from  his  numerous 
experiments  stated  the  following,  as  the  types  of  collateral  circula- 
tion: 

1.  Direct  collateral  circulation  is  established;  i.  e.,  there  are 
strongly-developed  vessels,  which  pass  from  the  central  end  of  tbf* 
artery  directly  to  the  peripheral  end. 

These  uniting  vessels  are 
chiefly  the  dilated  vasa  vasorum, 
and  the  vessels  of  the  thrombus ; 
it  might  happen  that  one  of 
these  uniting  vessels  should  di- 
late so  much  as  to  acquire  the 
appearance  of  being  simply  the 
trunk  regenerated. 

2.  There  is  an  indirect  col- 
lateral circulation ;  i,  e.,  the 
connecting  branches  of  the  next 
lateral  arteries  are  greatly  di- 
lated, as  in  the  following  case, 
Fig.  33. 

The  most  striking  examples 
of  both  varieties  of  collateral 
circulation  have  here  been  cho- 
sen ;  but  when  you  examine  the 
numerous  sketches  of  Porta^ 
and  yoiu-selves  repeat  these  ex- 
periments, you  will  find  that  in 
most  cases  direct  and  indirect 
collateral  circulation  are  com- 
bined, so  the  only  value  of  the 
classification  is  to  group  the 
different  forms  in  some  way. 

It  is  an  excellent  anatomi- 


Femoral  artery  of  a  large  dog;, 
after  ligation.    Afu 


injected  3  montbB 
T  Porta. 


CIRCULATION   AFTER   LIGATION.  137 

cal  exercise,  to  represent  for  yourselves  how,  after  ligation  of  the 
different  arteries  of  one  or  both  extremities,  or  of  the  trunk,  the 
blood  will  reach  the  parts  beyond  the  point  of  ligation  ;  in  this  you 
would  be  well  assisted  by  the  plates  of  arterial  anastomosis  in 
Krause^s  text-book  of  anatomy.  In  the  surgery  of  old  Conrad 
Martin  JLangenheck,  these  conditions  are  carefully  described  in  the 
chapter  on  aneurisms.  The  reversal  of  the  blood-current,  which 
not  unfrequently  takes  place  in  these  collateral  circulations,  occurs 
with  wonderful  rapidity,  when  the  anastomoses  are  free  ;  if,  for  in- 
stance, we  ligate  the  common  carotid  in  a  man,  and  then  divide  the 
artery  beyond  the  ligature,  the  blood  escapes  with  great  force  from 
the  peripheral  end,  that  is,  backward  as  from  a  vein.  In  all  such 
cases,  where  the  artery  to  be  ligated  has  free  anastomoses,  if  a  piece 
is  to  be  cut  out  of  the  artery,  we  should  first  ligate  both  central  and 
periphei'al  ends,  to  be  insured  against  haemorrhage  ;  this  is  an  im- 
portant practical  rule,  which  is  often  neglected. 

The  recent  investigations  on  the  formation  of  vessels  by  Arnold, 
already  spoken  of,  as  well  as  those  on  tubercle,  of  which  we  shall 
hereafter  speak,  have  given  new  material  for  the  view  that  the  sub- 
stance of  the  wall  of  the  vessel  as  well  as  its  endothelium  takes  an 
active  part  in  the  new  formation  ;  and  in  a  recently  published  work 
of  RiedeVs  it  is  stated  as  very  probable  that  the  greater  part  of  the 
young  tissue  formed  in  a  thrombus  proceeds  from  the  endothelium. 
Thus  the  views  on  this  subject  have  been  unsettled  for  years. 


CHAPTER   II. 
SOME  PECULIARITIES  OF  PUNCTURED  WOUNDS. 


LECTURE    X, 


A.8  a  Eule,  Punctured  Wounds  heal  quietly  by  First  Intention.— Needle  Punctures  ; 
Needles  remaining  in  the  Body,  their  Extraction.— Punctured  Wounds  of  the  Nerves. 
—Punctured  Wounds  of  the  Arteries  :  Aneurysma  Traumaticura,  Varicosum,  Varix 
Aueurysmaiicus. — Punctured  Wounds  of  the  Veins,  Venesection. 

Most  punctured  wounds  are  sim])le  wounds,  and  usually  heal  by 
first  intention ;  many  of  them  are  at  the  same  time  incised  wounds, 
when  the  puncturing  instrument  has  a  certain  breadth ;  some  have 
the  characteristics  of  contused  wounds,  when  the  puncturing  instru- 
ment was  blunt ;  in  this  case  there  is  generally  more  or  less  suppura- 
tion. We  make  many  punctured  wounds  with  our  surgical  instru- 
ments, as  with  acupuncture  needles — fine,  long  needles,  that  we 
occasionally  employ  to  examine  whether  and  how  deep  below  a  tumor 
or  ulcer  the  bone  is  destroyed,  etc. ;  with  acujyressure  needles,  which  we 
use  for  arresting  haemorrhage ;  with  the  trocar,  a  dagger  with  a  three- 
eided  point,  furnished  with  a  closely-fitting  canula,  an  instrument  for 
drawing  off  fluid  from  cavities. 

Dirk,  sword,  knife,  and  bayonet  punctures  are  often  simultaneously 
incised  and  contused  wounds.  If  these  punctured  wounds  be  not 
accompanied  by  injury  of  large  arteries,  veins,  or  bones,  and  do  not 
enter  any  of  the  cavities  of  the  body,  they  often  heal  rapidly  and 
Avithout  treatment. 

Tlie  most  frequent  punctured  wounds  are  those  made  with  needles, 
especially  in  women,  and  how  rarely  a  doctor  is  called  for  them  ! 
Such  an  injury  is  only  complicated  by  a  needle,  or  a  part  of  one,  en- 
tering the  soft  parts  so  deeply  that  it  cannot  readily  be  extracted. 
This  occasionally  happens  in  different  parts  of  the  body,  as  from  a 
person  sitting  or  falling  on  a  needle,  or  some  such  accident.  If  a 
needle  has  entered  deep  under  the  skin,  the  symptoms  are  usually  so 


NEEDLE  WOUNDS.  139 

slight  that  the  patients  rarely  have  any  decided  sensation  of  it ;  in- 
deed, they  often  cannot  say  whether  the  needle  has  really  entered 
and  where  it  is.  And  in  the  soft  parts  this  body  usually  induces  no 
external  symptoms,  but  may  be  carried  in  the  body  for  months,  years, 
or  even  a  lifetime,  without  trouble,  if  it  do  not  enter  a  nerve.  The 
needle  rarely  remains  stationary  at  the  point  where  it  entered,  but 
wanders  about ;  it  is  shoved  along  to  other  parts  of  the  body  by  con- 
traction of  the  muscles,  and  thus  may  come  to  light  a  long  distance 
from  the  point  of  entrance.  Cases  have  been  observed  where  hyster- 
ical women,  from  the  peculiar  vanity  of  attracting  the  attention  of 
physicians,  have  inserted  numerous  needles  in  different  parts  of  the 
body;  these  needles  appeared  now  here,  now  there.  Even  when 
needles  have  been  swallowed,  they  may  without  danger  pass  through 
the  walls  of  the  stomach  and  intestines,  and  come  to  the  surface  at 
any  part  of  the  abdominal  wall.  B.  von  Langenbeck  found  a  pin  in 
the  centre  of  a  vesical  calculus  ;  on  more  careful  inquiry,  it  was  found 
that,  when  a  child,  the  patient  had  swallowed  a  pin.  The  pin  may 
have  passed  through  the  intestine  into  the  bladder  ;  here  triple  jDhos- 
phates  were  deposited  around  it  in  layers,  and  this  was  possibly  the 
origin  of  the  calculus.     Dittle  had  a  similar  experience. 

WTien  the  needle  has  remained  for  a  time  in  the  soft  parts  without 
exciting  pain,  or  when  needles,  passing  through  the  body  from  within 
outward,  come  to  the  surface  close  under  the  skin,  they  usually  excite 
a  little  suppuration ;  the  piercing  feeling  becomes  more  decided  ;  we 
make  an  incision  at  the  painful  spot,  let  out  a  little  thin  pus,  and  in 
the  pus-cavity  find  the  needle,  which  may  be  readily  removed  with 
forceps.  It  is  difficult  to  explain  why  this  body,  which  for  months 
has  moved  about  in  the  body,  should  at  length  excite  suppuration 
when  it  arrives  under  the  skin  ;  you  must  here  satisfy  yourselves  with 
a  simple  knowledge  of  the  facts.  The  following  interesting  case  may 
render  the  course  of  these  injuries  more  clear  to  you :  In  Zurich  a 
perfectly  idiotic  female  deaf  mute,  thirty  years  old,  was  brought  to 
the  clinic  with  the  diagnosis :  typhus.  No  history  of  the  case  could 
be  obtained  from  the  patient  or  those  about  her,  who  were  also  lack- 
ing in  intelligence.  The  patient,  who  often  remained  in  bed  for  days, 
had  complained  for  a  short  time  of  pain  in  the  ileo-csecal  region,  and 
had  moderate  fever.  Examination  showed  a  swelling  at  this  point, 
which  increased  the  following  days,  and  was  very  painful  on  pressure ; 
the  skin  reddened,  fluctuation  became  evident.  It  was  clearly  not  a 
case  of  typhus,  but  you  may  imagine  what  different  diagnoses  there 
were  as  to  the  seat  of  the  suppuration,  for  there  was  undoubtedly  an 
abscess  ;  it  might  be  inflammation  of  the  ovary,  perforation  of  the 
vermiform  process,  an  abscess  in  the  abdominal  walls,  etc.,  etc.  ;  still. 


140 


SOME   PECULIAKITIES   OF   PUNCTURED   WOUNDS. 


somethino:  could  be  said  against  all  these  hypotheses.  After  a  few 
days  the  reddened  skin  became  very  thin,  the  abscess  pointed  about 
the  height  of  the  anterior  s'lperior  spinous  process  of  the  ilium,  a  few 
fingers'  breadths  above  Poupart's  ligament,  and  I  made  an  incision 
through  the  skin ;  there  was  evacuated  a  gassy,  brownish,  sanious  pus, 
with  a  strong  fecal  odor.  As  I  examined  the  abscess-cavity  with  my 
finger,  I  felt  a  hard,  rod-like,  firm  body  in  the  depth  of  the  abscess, 
and  projecting  slightly  into  it.  I  began  to  extract  it,  and  pulled  and 
pulled  till  I  brought  out  a  knitting-needle  almost  a  foot  long,  w^hich 
was  somewhat  rusty  and  pointed  down  toward  the  pelvis.  The  ab- 
scess-cavity was  clothed  with  flabby  granulations.  When  I  tried  to 
examine  tlie  opening  that  the  needle  must  have  left  behind,  I  coidd 
no  longer  find  it ;  it  had  closed  again,  and  was  covered  by  the  granu- 
lations. The  abscess  took  a  long  time  to  heal ;  it  at  last  did  so 
without  further  accident,  so  that  in  four  weeks  the  patient  was  dis- 
missed. As  I  showed  the  unfortunate  cretin  the  extracted  needle,  she 
laughed  in  her  idiotic  way ;  that  was  all  we  could  make  out  of  her ; 
perhaps  this  may  have  indicated  some  slight  recollection  of  the  needle. 
It  is  most  probable  that  the  patient  had  inserted  the  needle  into  the 
vagina  or  rectum — procedures  in  wdiich  even  women  not  idiotic  find 
some  incredible  pleasure,  as  you  may  see  in  DieffenhacIC s  operative 
surgery  in  the  chapter  on  extraction  of  foreign  bodies.  It  is  not  im- 
possible that  in  this  case  the  needle  passed  by  the  side  of  the  vaginal 
portion  of  the  uterus  through  the  cfficum,  for,  from  the  gas-containing 
pus  of  the  abscess,  we  may  decide  that  there  was  at  least  a  temporary 
communication  with  the  intestine.  It  is  true  this  cannot  be  regarded 
as  absolutely  certain,  for  pus  in  the  vicinity  of  the  intestines  by  the 
development  of  stinking  gases  may  putrefy,  even  when  no  communi 
cation  with  the  interior  of  the  intestines  exists  or  has  existed. 

The  extraction  of  recently-entered  needles  may  be  very  difficult, 
especially  as  the  patients  are  not  unfrequently  very  undecided  in  their 
information  about  the  location  of  the  body,  and  occasionally  from 
shame  w^ill  not  acknowledge  how  the  needles  (in  the  bladder,  for  in- 
stance) obtained  entrance.  We  should,  wath  the  left  hand,  fix  the 
spot  where  we  shall  most  probably  find  the  foreign  bodj'^,  carefully 
endeavoring  to  press  the  skin  together  in  folds ;  we  must  at  the  same 
time  be  careful  that  the  needle  does  not  again  change  its  position 
while  we  are  making  the  incision.  Sometimes  we  feel  the  body  more 
or  less  distinctly,  and  can  cause  pain  by  pressing  on  it ;  these  attempts 
must  decide  the  point  of  our  incision.  After  dividing  the  skin,  we 
attempt  to  seize  the  needle  with  a  pair  of  good  dissecting  forceps ; 
very  tense  bands  of  fascia  may  readily  deceive  us,  especially  about 
the  fingers,  for  with  forceps  our  sense  of  feeling  is  always  uncertain. 


EXTRACTION   OF  FOREIGX  BODIES.  141 

If  we  cannot  find  the  needle,  we  may  move  the  parts  some  ;  tlip 
needle  is  then  sometimes  moved  into  a  position  where  it  may  ht- 
seized  more  readily.  The  extraction  of  foreign  bodies  requires  a  cer- 
tain amount  of  practice  and  manual  dexterity,  which  we  acquire  only 
with  time  and  practice ;  here  natural  knack  is  of  great  service. 

Punctured  wounds,  made  with  instruments  not  very  sharp,  are 
occasionally  interrupted  in  their  process  of  healing.  Externally  they 
heal  by  first  intention,  but  after  a  few  days  there  are  suppuration  and 
inflammation  in  the  deeper  parts ;  the  wound  either  opens,  and  the 
whole  tract  of  the  wound  suppurates,  or  the  pus  breaks  through  at 
some  other  point.  This  occurs  particularly  in  cases  where  a  foreign 
body,  as  the  point  of  a  knife,  remains  behind,  or  where  the  wound 
was  made  with  a  blunt  instrument.  In  examining  the  wound,  you 
should  always  bear  in  mind  the  possibility  of  a  foreign  body  remain- 
ing behind,  and,  if  possible,  see  the  instrument  with  which  the  injury 
was  done,  and  find  exactly  in  what  direction  the  instrument  passed,  so 
that  you  may  know  about  what  parts  are  injured.  However,  even  in 
imfavorable  cases  there  are  occasionally  very  little  inflammation  and 
suppuration.  A  short  time  since  a  man  came  to  the  clinic  who,  a  few 
days  previously,  had  fallen  a  moderate  height  from  a  tree,  lighting  on 
his  left  arm,  while  engaged  clipping  the  small  branches.  On  the  dor- 
sal surface,  a  few  inches  below  the  elboAV,  the  arm  was  swollen ;  on 
the  volar  surface,  just  above  the  wrist,  there  was  a  slight  excoriation ; 
the  arm  could  be  extended  and  flexed  without  pain  ;  only  pronation 
and  supination  were  impaired  and  painful.  There  was  no  solution  of 
continuity  of  the  bones  of  the  forearm ;  the  bones  were  certainly  not 
broken  through.  At  the  swollen  spot  on  the  dorsal  side,  an  inch 
below  the  elbow,  immediately  under  the  skin,  we  could,  however,  feel 
a  firm  body,  which  could  be  pressed  back  somewhat,  but  it  at  once 
returned  to  its  old  position.  It  felt  just  as  if  a  piece  of  bone  had 
been  broken  ofT  lengthwise,  and  lay  close  under  the  skin.  Incompre- 
hensible as  it  must  seem  for  such  a  detachment  of  bone  to  occur  by 
simply  falling  on  the  arm,  without  fracture  of  the  radius  or  ulna,  I 
nevertheless  had  the  patient  ancesthetized,  and  again  made  the  at- 
tempt to  press  into  position  the  suspected  fragment ;  but  it  did  not 
succeed.  As  it  lay  so  close  under  the  skin  that  it  would  necessarily 
have  perforated  ere  long,  I  made  a  small  incision  through  the  skin  to 
extract  it.  To  our  great  astonishment,  I  drew  out,  not  a  fragment 
of  bone,  but  a  small  branch,  five  inches  long,  which  was  quite  firmly 
held  by  the  two  bones  of  the  forearm.  It  was  incomprehensible  how 
this  tM'ig  could  have  entered  the  forearm ;  but,  on  more  careful 
examination  at  the  above-mentioned  excoriated  spot  on  the  volai 
Siorface,  we  found  a  linear,  slit-like  wound,  which  had  already  closed, 


142  SOME  PECULIARITIES   OF   PUXCTURED   WOUxVDS. 

Ihrough  which  the  body  had  apparently  passed  so  quickly  that  the 
patient  had  not  noticed  its  entrance.  After  its  extraction  the  very 
moderate  swelling  entirely  subsided;  the  small  wound  discharged 
but  little  pus,  and  was  entirely  closed  in  eight  days. 

Tliese  favorable  conditions  of  punctured  wounds  have  given  rise 
to  the  so-called  subcutaneous  operations,  which  were  introduced  into 
suro-ery  more  particularly  by  Stromeyer  and  Dieffenhach,  and  consist 
in  passing  a  pointed,  narrow  knife  under  the  skin,  and  dividing  ten- 
dons, muscles,  or  nerves,  for  various  purposes  of  treatment,  without 
making  any  wound  in  the  skin  other  than  the  small  punctm-ed  wound 
through  which  the  tenotome  is  introduced.  Under  these  circum- 
stances the  w-ound  almost  always  quickly  closes  by  first  intention, 
while  in  open  wounds  of  tendons  there  is  almost  always  suppuration, 
often  extensive  death  of  the  tendon.  Of  this  we  shall  speak  further 
in  the  chapter  on  deformities  (Chapter  XVIII.). 

If  the  puncture  has  entered  one  of  the  cavities  of  the  bod}^,  and 
caused  injury  there,  the  prognosis  wiU  always  be  doubtful ;  there  is 
more  or  less  danger,  according  to  the  physiological  importance  and 
vulnerability  (the  greater  or  less  susceptibility  to  dangerous  inflam- 
mation) of  the  organ  implicated.  Such  a  punctured  wound  is  not  so 
dangerous  as  a  gunshot  wound.  "We  shall  not  at  present  pursue  this 
subject  further,  but  must  now  say  something  about  punctured  wounds 
of  the  nerves  and  arteries  of  the  extremities. 

Punctured  wounds  of  nerves  naturally  induce,  according  to  their 
extent,  paralysis  of  variable  amount;  otherwise  they  have  the  same 
effect  as  incised  wounds  of  the  nerves.  Regeneration  occurs  the 
more  readily  when  the  whole  breadth  of  the  nerve  has  not  been  punc- 
tured. The  case  is  different  when  a  foreign  bodj^,  as  the  point  of  a 
needle  or  a  bit  of  glass,  is  left  in  the  nerve-trunk ;  they  may  heal  in 
here  as  in  other  tissues.  The  cicatrix  in  the  nerve  which  contains  this 
body  may  remain  excessively  painful  at  every  touch  ;  there  may  also 
be  neuralgia  or  nervous  pains  extending  excentrically.  Moreover, 
the  severest  nervous  diseases,  acute  or  chronic,  ma}'^  be  induced  by 
these  foreign  bodies.  EpileiMform  spasms,  with  an  aura,  a  pain  in 
the  cicatrix  preceding  the  spasm,  have  been  observed  after  such  in- 
juries ;  some  surgeons  also  assert  that  traumatic  tetanus  may  also  be 
induced  by  this  nei-vous  irritation.  Tliis  appears  to  me  very  doubtful, 
but  of  this  hereafter.  The  first  of  these  diseases,  the  so-called  reflex 
epilepsy,  may  usually  be  cured  by  the  extraction  of  the  foreign  body. 

Punctured  wounds  of  arterial  trunks  or  their  large  branches  may 
induce  various  results.  A  very  small  puncture  usually  closes  by  the 
elasticity  and  contractility  of  the  coats ;  indeed,  there  is  not  always 
a  haemorrhage,  any  more  than  there  is  always  escape  of  faeces  from 


PUNCTURED   WOUNDS   OF   ARTERIES.  I43 

a  small  puncture  of  the  intestine.  If  the  wound  be  slit-shaped,  the 
bleeding-  may  also  be  insig-nificant  if  the  opening  g-cipes  but  little ; 
but  in  other  cases  severe  arterial  haemorrhage  is  the  immediate  result. 
If  compression  be  at  once  made,  and  a  bandage  accurately  applied, 
we  shall  usually  succeed  not  only  in  arresting  the  haemorrhage,  but 
also  in  closing  the  puncture  in  the  artery,  just  as  we  should  one  in  the 
soft  parts.  If  the  bleeding  be  not  arrested,  as  already  stated,  we 
shpuld  at  once  ligate  the  artery,  after  enlarging  the  wound  up  and 
downward,  or  at  a  higher  point  in  the  continuity. 

The  closure  of  the  arterial  wound  takes  place  as  follows :  A  blood- 
clot  forms  in  the  more  or  less  gaping  wound  of  the  arterial  wall ;  this 
clot  projects  slightly  into  the  calibre  of  the  vessel ;  but  externally  it 
is  usually  somewhat  larger,  and  looks  like  a  mushroom.  As  described 
in  intra-vascular  thrombus,  this  clot  is  transformed  to  connective 
tissue ;  and  thus  there  is  permanent  organic  closure,  without  change 
of  the  calibre  of  the  artery.  This 
normal  course  may  be  complicated  ^'Q-  34. 

by  layers  of  new  fibrine  from  the 
circulating  blood,  depositing  on 
the   part   of   the   plug   projecting 

into  the  calibre  of  the  vessel,  and 

,1  1      •        •,   -1  ^    i.    c         •  Artery  wounded  on  the  side,  with  clot,  fear 

thus  Closmg  it  by  a  clot,  fornung  a  ;aays  after  the  injury;  Sifter  Forta. 

complete  arterial  thrombosis ;  but 

this  is  rare.  Should  it  happen,  we  would  have  the  same  result  as 
after  a  thrombosis  following  ligation — development  of  collateral  cir- 
culation, and  eventual  obliteration  of  the  vessel  by  organization  of 
the  thrombus. 

Punctured  wounds  of  the  arteries  do  not  always  take  so  favorable 
a  course.  In  many  cases,  soon  after  the  injury,  we  notice  a  tumor  at 
the  seat  of  the  young  cutaneous  cicatrix,  which  gradually  enlarges 
and  perceptibly  pulsates  isochronically  with  the  systole  of  the  heart 
and  with  the  arterial  pulse.  If  we  place  a  stethoscojDe  over  the 
tumor,  we  may  hear  a  distinct  buzzing  and  friction  sound.  If  we 
compress  the  chief  artery  of  the  extremity  above  the  tumor,  the  pul- 
sation and  mm-mur  cease  and  the  tumor  diminishes  somewhat.  We 
call  such  a  tumor  an  aneurism  (from  avevpvvetv,  to  dilate),  and  this 
particular  form,  arising  from  wound  of  an  artery,  we  call  aneurisma 
spurium  or  traumaticum,  in  contradistinction  to  the  aneurisma 
verum,  arising  spontaneously  from  other  diseases  of  the  artery. 

Whence  comes  this  tumor,  and  what  is  it  ?  Its  origin  is  as  fol- 
lows :  The  external  wound  is  closed  by  pressure,  the  blood  can  no 
longer  flow  out  of  it ;  but  it  forms  a  way  through  the  opening,  which 
is  not  yet  firmly  closed  by  the  clot,  into  the  soft  parts,  and  winds 


114 


SOME   PECULIARITIES   OF   PUNCTURED   WOUNDS. 


about  among  them  as  long  as  the  pressure  of  the  blood  is  stronger  than 
the  resistance  of  the  tissues ;  a  cavity  filled  with  blood  is  formed  in 
immediate  communication  with  the  calibre  of  the  artery,  part  of  the 
blood  soon  coagulates,  and  there  is  shght  inflammation  of  the  tissue 

about  it ;  a  plastic  infiltra- 
Fio.  35.  tration,  which  leads  to  con- 

nective tissue  new  forma- 
tion, and  this  thickened 
tissue  forms  a  sac,  into 
and  from  whose  cavity  the 
blood  flows,  while  the  pe- 
riphery of  the  cavity  is 
filled  with  layers  of  clotted 
blood.  The  buzzing  and 
friction  that  we  perceive 
in  the  tumor  arise  partly 
from  the  blood  flowdng  out 
through  the  narrow  open- 
ing in  the  artery,  partly 
by  its  friction  against  the 
coagulum,  and  lastly  by 
the  regurgitation  of  tlie 
blood  into  the  artery. 

Such  a  traumatic  an- 
eurism may  also  occur  in 
another,  more  secondary 
way  ;  the  arterial  wound 
at  first  heals,  and  subse- 
quently, after  removal  of 
the  pressure  bandage,  the 
young  cicatrix  gives  way, 
and  then  for  the  first  time 
the  blood  escapes. 
Traumatic  aneurisms  are  not  always  caused  by  punctured  wounds 
of  arteries,  but  rupture  of  their  coats  by  great  tension  and  contusions, 
without  any  external  wound,  may  result  in  their  development.  Thus, 
in  his  surgical  lectures,  A.  Cooper  tells  of  a  gentleman  who  leaped  a 
ditch  while  out  shooting,  and  at  the  time  felt  a  pain  in  the  hollow  of 
his  knee,  which  prevented  his  walking.  An  aneurism  of  the  popliteal 
artery  soon  developed  in  the  bend  of  the  knee,  that  finally  had  to  be 
operated  on.  The  artery  was  partly  ruptured  by  the  leap.  Rupture 
of  the  tunica  intima  and  muscularis  is  sufficient  to  permit  the  forma- 
tion of  an  aneurism.     Should  the  tunica  adventitia  remain  uninjured. 


Aneurisma   iraumaticum   of  the  brachial  artery ;  after 
Froriep,  "  Surgical  Copperplates."    Bd.  IV.,  Plate  483. 


ANEURISM   FROM   PUNCTURED    WOUNDS. 


115 


I 


the  blood  may  detach  it  from  the  tunica  media;  this  forms  a  variety 
of  aneurism  called  aneurisma  dissecans  (dissecting  aneurism).  Cases 
of  punctured  wounds  with  subsequent  aneurisms  occur  particularly  in 
military  practice,  but  not  unfrequently  also  in  civU  practice.  I  saw  a 
boy  with  an  aneurism,  as  large  as  a  hen's-egg,  of  the  femoral  artery, 
about  the  middle  of  the  thigh,  that  had  been  caused  by  puncture  with 
a  pen-knife,  on  which  the  boy  fell.  A  short  time  since  I  operated  on 
an  aneurism  of  the  radial  artery,  that  had  developed  m  a  shoemaker 
after  an  accidental  puncture  with  an  awl. 

An  aneurism  is  a  tumor  communicating  directly  or  indirectly 
with  the  calibre  of  an  artery.  This  is  the  common  definition.  The 
communication  is  immediate  in  the  case  just  described  of  a  simple 
traumatic  aneurism.  Still,  the  anatomical  conditions  of  this  tumor 
may  be  more  complicated. 

For  instance,  in  a  venesection  at  the  bend  of  the  elbow,  that  is, 
from  intentionally  puncturing  a  vein  for  the  purpose  of  abstracting 
blood,  besides  the  vein,  the  brachial  artery  may  be  wounded  ;  this  is 
one  of  the  most  frequent  causes  of  traumatic  aneurism,  or  at  least  was 
so  formerly,  when  bleeding  was  more  common.  In  such  a  case,  besides 
the  dark,  venous  blood,  we  may  readily  perceive  the  bright,  arterial 
blood ;  the  whole  arm  is  at  once  bound  up  and  the  artery  compressed, 
and  in  some  cases  the  openings  in  both  vessels  heal  at  once  without 
further  consequences.  But  occasionally  it  happens  that  this  accident 
is  followed  by  an  aneurism ;  this  may  have  the  simple  form  above  de- 
scribed ;  but  the  openings  in  the  two  vessels  may  so  grow  together  that 
part  of  the  arterial  blood  will  flow  directly  into  the  vein  as  into  an 
arterial  branch,  and  must  then  meet  the  stream  of  venoug  blood.    This 


Fia.  36. 


Varu  sneurismaticus.     a.  Brachial  artery ;  after  i3eW.   Froriep,   "  Snrgical    Copperplates.'' 

Bd.in.,  Taf.  263. 
11 


146 


SOME  PECULIARITIES   OF  PUNCTURED   WOUNDS. 


causes  obstruction  of  tlie  venous  current  and  consequent  sacculations, 
dilatations  of  the  calibre  of  the  vein,  which  we  generally  term  vari- 
ces '  in  this  particular  case  the  varix  is  called  varix  a?ieurismaticus, 
because  it  communicates  with  an  artery  like  an  aneurism. 

Another  case  may  arise :  an  aneurism  forms  between  the  artery  and 
vein,  both  of  which  communicate  with  the  aneurismal  sac. 


Fia.  37. 


,  varicosnm.    a,  Brachial  artery;  6,  median  vein.    The  aneurismal  sac 
after  Borsey.    Froriep,  "Surgical  Copperplates."    Bd.  III.,  Taf.  263. 


The  aneurismal  sac  is  cut  open  ; 


We  call  this  aneurisma  varicosum.  Tliere  may  also  be  some 
varieties  in  the  relation  of  the  aneurismal  sac,  vein,  and  artery,  to  each 
other,  which,  however,  are  only  important  as  being  curious,  and  change 
neither  the  syrnptoms  nor  treatment,  and  fortunately  have  no  particular 
names.  In  all  these  cases  where  arterial  blood  flows  directly  or  indi- 
rectly through  an  aneurismal  sac  into  the  veins,  there  is  distention  of 
the  veins  and  a  thrill  in  them,  which  may  be  both  felt  and  heard,  and 
may  even  be  occasionally  perceived  in  the  arteries ;  it  probably  results 
from  the  meeting  of  the  currents.  However,  this  thrill  in  the  vessels 
is  not  characteristic  of  the  above  state,  for  it  may  sometimes  be  in- 
duced simply  by  pressure  on  the  veins,  and  occurs  in  some  diseases  of 
the  heart.  We  also  occasionally  see  a  weak  pulsation  in  veins  dis- 
tended by  the  above  causes,  which  would  even  earlier  give  a  correct 
diagnosis. 

Quite  recently  I  saw  a  number  of  aneurisms  resulting  from  gun- 
shot-wounds ;  in  three  cases  affecting  the  femoral  and  external  iliac 
arteries,  the  above-mentioned  thrill  was  very  prominent,  rendering  it 
pretty  certain  that  there  was  a  communication  between  the  artery 
and  vein,  as  was  proved  by  autopsy  in  one  case ;  but  there  were  no 
varices  in  any  of  these  cases ;  hence  their  development  is  not  a  neces* 


VENESECTION.  147 

sarj  result  of  communication  between  arteries  and  veins,  or  else  they 
may  in  some  cases  not  develop  for  some  years. 

Aneurisms  of  the  arteries,  in  whatever  form  they  come,  if  they 
only  remained  small,  would  cause  no  great  inconvenience.  But  in 
most  cases  the  aneurismal  sacs  grow  larger  and  larger ;  functional  dis- 
turbances occur  in  the  affected  extremity,  and  finally  the  anevu-ism 
may  rupture,  and  a  profuse  hsemorrhage  terminate  life.  In  most  cases 
the  treatment  must  consist  in  ligating  the  aneurismal  artery ;  but  of 
this  hereafter.  I  have  considered  it  practical  to  explain  to  you  here 
the  development  of  traumatic  aneurisms,  as  in  practice  they  are  mostly 
due  to  punctured  wounds ;  while  in  other  text-books  you  will  find  them 
systematically  treated  of  among  diseases  of  the  arteries.  We  shall 
speak,  in  a  separate  chapter,  of  spontaneous  aneurisms  and  their  treat- 
ment. 

Punctured  wounds  of  veins  heal  just  like  those  of  arteries,  so  that 
I  need  add  nothing  here  to  what  was  said  above ;  we  need  only  re- 
mark here  that  extensive  coagulations  form  more  readily  in  veins  than 
in  arteries;  traumatic  venous  thrombosis  after  venesection,  for  in- 
stance, is  far  more  frequent  than  traumatic  arterial  thrombosis  after 
punctured  wounds  of  arteries,  and,  what  is  far  worse,  the  former  variety 
of  thrombosis  has  much  more  serious  results  than  the  latter ;  on  this 
point  you  Avill  perhaps  hereafter  hear  more  than  will  be  agreeable  to 
you. 

We  have  frequently  mentioned  venesection,  which  is  a  very  frequent 
small  surgical  operation.  We  shall  here  briefly  re\dew  its  performance, 
although  you  comprehend  such  things  quicker  and  better  by  once  see- 
ing them  than  I  could  represent  them  to  you.  Should  I  attempt  to  tell 
you  under  what  circumstances  venesection  should  be  performed,  I 
should  have  to  enter  deeply  into  the  whole  subject  of  medicine ;  quite 
a  large  book  might  be  written  on  the  indications  and  contraindications, 
the  admissibility,  the  benefits  and  injuries  of  venesection ;  hence  I  pre- 
fer to  say  nothing  on  these  points  as  on  so  many  others  which  you  will 
pick  up  in  a  few  minutes  at  your  daily  \asits  to  the  clinics,  and  for 
whose  theoretical  exposition  without  special  cases  we  should  require 
hours.  In  regard  to  the  history,  we  will  only  mention  that,  while  for- 
merly venesection  was  performed  on  any  of  the  subcutaneous  veins, 
now  it  is  only  done  in  the  veins  of  the  bend  of  the  elbow.  If  you 
wish  to  bleed  a  patient,  you  first  apply  a  pressure-bandage  to  the  arm, 
to  cause  obstruction  of  the  peripheral  veins ;  for  this  purpose  we  em- 
ploy a  properly-appHed  handkerchief  or  the  old-fashioned  scarlet  bleed- 
ing-ribbon, a  firm  bandage  two  or  three  finger-breadths  wide  with  a 
buckle ;  when  this  is  firmly  applied  the  veins  of  the  forearm  swell  up 
and  the  vena  cephalica  and  basilica  with  their  corresponding  median 


148  SOME  PECULIARITIES   OF  PUXCTURED   WOUNDS. 

reins  appear  in  the  bend  of  the  elbow.  You  choose,  for  opening,  the 
vein  which  is  most  prominent.  The  arm  of  the  patient  is  flexed  at  an 
obtuse  angle ;  with  the  left  thumb  you  fix  the  vein,  with  the  lancet  or  a 
very  pointed  straight  scalpel  in  the  right  hand  you  puncture  the  vein 
and  slit  it  up  longitudinally  two  or  three  Unes.  The  blood  escapes  in  a 
stream ;  you  allow  sufficient  to  flow,  cover  the  puncture  with  your 
thumb,  remove  the  bandage  from  the  arm  above,  and  the  bleeding  will 
cease  spontaneously ;  the  wound  should  be  covered  with  a  small  com- 
press and  a  bandage ;  the  arm  should  be  kept  quiet  three  or  four  days, 
then  the  woimd  will  be  healed.  Easy  as  this  operation  is  in  most 
cases,  it  still  requires  practice.  Puncture  with  the  lancet  or  scalpel  is 
to  be  preferred  to  the  spring-lancet;  the  latter  was  formerly  very  pop- 
ular, but  is  now  very  justly  going  out  of  fashion ;  the  spring-lancet  is  a 
so-called  fleam,  which  is  driven  into  the  vein  with  a  spring;  we  allow 
the  instrument  to  operate,  instead  of  doing  it  ourselves  more  certainly 
with  the  hand. 

Various  obstacles  may  interfere  with  venesection.  In  very  fat  per- 
sons it  is  often  difficult  to  see  or  feel  the  veins  through  the  skin ;  then 
besides  compression  we  employ  another  means,  that  is  holding  the 
forearm  in  warm  water,  which  increases  the  afflux  of  blood  to  this  part 
of  the  body.  Moreover,  after  opening  the  vein  the  fat  may  impede  the 
escape  of  the  blood  by  fat-lobules  lying  in  the  opening;  these  should 
be  quickly  snipped  off  with  the  scissors.  Occasionally  the  flow  of 
blood  is  mechanically  obstructed  by  the  arm  being  rotated  or  bent  at 
a  different  angle  after  the  puncture  has  been  made,  so  that  the  open- 
ing in  the  vein  no  longer  corresponds  to  that  in  the  skin ;  this  is  to  be 
met  by  changing  the  position  of  the  arm.  There  are  other  causes  for 
the  blood  not  flowing  properly ;  such  as  the  puncture  being  too  small, 
a  frequent  fault  with  beginners ;  the  compression  is  too  weak,  this  may 
be  improved  by  tightening  the  bandage  ;  or,  on  the  contrary,  the  com- 
pression is  too  great,  so  that  the  artery  is  also  compressed,  and  little 
or  no  blood  flows  from  the  arm,  this  may  be  obviated  by  loosening  the 
venesection  bandage.  Aids  for  increasing  the  flow  of  blood  are:  dip- 
ping the  hand  in  Avarm  water,  and  having  the  patient  rhythmically 
open  and  close  the  hand,  so  that  the  blood  may  be  forced  out  by  the 
muscular  contractions.  We  shall  speak  further  on  this  point,  as  op 
portunity  offers,  in  the  clinic. 


I 


CHAPTER  III. 

COJVTVSIOJ^S   OF  THE  SOFT  PARTS    WITHOUT 
WOUI^DS. 


LECTURE  XI. 


Causes  of  Contusions. — Nervous  Concussion. — Subcutaneous  Eupture  of  Vessels. — Rup- 
ture of  Arteries. — Suggillations. — Eccbymoses. — Eeabsorption. — Termination  in 
Fibrous  Tumors,  in  Cysts,  in  Suppuration,  and  Putrefaction. — Treatment. 

By  the  action  of  a  blunt  object  on  tlie  soft  parts,  the  skin  will 
sometimes  be  injured,  sometimes  it  will  not ;  hence  we  distinguish  con- 
tusions with  or  without  wounds.     We  shall  first  consider  the  latter. 

Tliese  contusions  are  partly  caused  by  the  falling'  or  striking  of  heavy 
objects  on  the  body,  partly  by  the  body  falling  or  striking  against  a 
hard,  firm  object.  The  immediate  result  of  such  a  contusion  is  a 
crushing  of  the  soft  parts,  which  may  be  of  any  grade ;  often  we  per- 
ceive scarcely  any  change,  in  other  cases  the  parts  are  ground  to  a 

pulp- 

Whether  the  skin  suffers  solution  of  continuity  by  this  application  of 
force  depends  on  various  circumstances,  especially  on  the  form  of  the  con- 
tusing body  and  the  force  of  the  blow,  also  on  the  nature  of  the  parts  un- 
der the  skin ;  for  instance,  the  same  force  would  cause  contusion  without 
a  wound  in  a  muscular  thigh,  that  applied  to  the  spine  of  the  tibia  would 
cause  a  wound,  for  in  the  latter  case  the  sharp  edge  of  bone  would  cut 
the  skin  from  within  outward.  The  elasticity  and  thickness  of  the 
skin  also  come  into  consideration ;  these  not  only  vary  in  different  per- 
sons, but  may  differ  in  different  parts  of  the  body  of  the  same  indi- 
vidual. 

In  contusion  without  wound  we  cannot  immediately  recognize  the 
amount  of  destruction,  but  only  indirectly  from  the  state  of  the  nerves 
and  vessels,  and  also  from  the  subsequent  course. 

In  contusion  the  first  symptom  in  the  nerves  is  pain,  just  as  it  is 


150        CONTUSIONS  OF   THE   SOFT   PARTS   WITHOUT   WOUNDS. 

in  wounds,  but  pain  of  a  duller,  more  undefined  character,  although 
it  may  be  very  severe.  In  many  cases,  especially  when  he  has  struck 
against  a  hard  body,  the  patient  has  a  peculiar  vibrating,  threatening 
feeling  in  the  injured  part;  this  feeling,  which  extends  some  distance 
beyond  the  seat  of  injury,  is  caused  by  the  co7icussion  of  the  nerves. 
Fo'r  instance,  if  we  strike^he  hand  or  finger  quite  hard,  only  a  small  part 
is  actually  contused,  but  not  unfrequently  there  is  concussion  of  the 
nerves  of  the  whole  hand,  with  great  trembling,  dull  pain,  on  account  of 
which  the  fingers  cannot  be  moved,  and  there  is  almost  complete  loss  of 
feeling  for  the  moment.  This  condition  passes  off  quickly,  usually  in  a  few 
seconds,  and  then  a  burning  pain  is  felt  in  the  contused  part.  The 
only  explanation  we  have  of  this  temporary  symptom  is  that  the 
nerve-substance  of  the  axis  cylinder  suffers  molecular  displacement 
from  the  blow,  which  spontaneously  passes  off  again.  These  symptoms 
of  concussion  (the  commotion)  do  not  by  any  means  accompany  all 
contusions ;  they  fail  especially  in  cases  where  a  heavy  body  comes 
against  a  limb  at  rest,  but  they  are  not  unfrequently  of  great  signifi- 
cance in  contusions  of  the  head ;  here  commotio  cerebri  is  not  unfre- 
quently united  with  contusio  cerebri,  or  the  former  appears  alone,  for 
instance,  in  a  fall  on  the  feet  or  buttocks,  whence  the  concussion  is  prop- 
agated to  the  brain  and  may  induce  very  severe  accidents  or  even 
death,  without  any  preceptible  anatomical  changes.  Concussion  is  es- 
sentially a  change  in  the  nervous  sj^stem,  hence  we  speak  chiefly  of 
cerebral  or  spinal  concussion.  But  the  peripheral  nerves  also  may  be 
concussed  with  the  above  symptoms;  but  since  in  such  cases  the  more 
locaKzed  contusion  is  especially  prominent,  this  nervous  state  is  per- 
haps too  much  neglected.  Severe  concussion  of  the  thorax  may  in- 
duce the  most  dangerous  symptoms  simply  from  concussion  of  the 
cardiac  and  pulmonary  nerves,  whereby  the  circulation  and  respiration 
are  disturbed,  although  for  the  most  part  only  temporarily.  Nor  can 
a  reflex  action  of  the  concussed  nerve,  especially  of  the  sympathetic 
on  the  brain,  be  entirely  denied.  Doubtless  some  of  you,  when  wrestling 
or  boxing,  have  received  a  blow  in  the  abdomen ;  what  terrible  pain  ! 
a  feeling  of  faintness  almost  overcomes  you  for  a  time ;  here  we  have  an 
action  on  the  brain  and  on  the  heart;  one  holds  his  breath  and  gathers 
his  strength,  to  prevent  sinking  to  the  earth.  Concussion  of  the  ulnar 
nerve  often  occurs,  when  we  strike  the  elbow  hard ;  most  of  you  proba- 
bly know  the  hea^^?^,  dull  pain,  extending  even  to  the  little  finger. 
Compression  of  sensitive  nerves  is  said  to  cause  contraction  of  the 
cerebral  vessels,  as  is  shown  by  recent  experiments  on  rabbits ;  possi- 
bly this  explains  the  faintness  from  severe  pain. 

All  these  are   symptoms  of  concussion  in  the  peripheral  nerves. 
Now,  as  we  do  not  know  what  specially  takes  place  in  the  nerves,  we 


CONTTJSIOXS   OF  XERVES  AXD   VESSELS.  151 

cannot  judge  whether  these  changes  have  any  effect,  and,  if  so,  what,  on 
the  subsequent  course  of  the  contusion,  and  of  the  contused  wound ; 
hence  we  cannot  here  study  the  nerves  any  further.  Some  unim- 
peachable observations  seem  to  prove  that  this  concussion  of  periph- 
eral nerves  may  induce  motor  and  sensory  paralysis,  as  well  as  atrophy 
of  the  muscles  of  a  limb ;  but  the  connection  between  cause  and  effect 
is  often  difficult  to  prove. 

Contusions  of  the  nerves  are  distinguished  from  concussions  by 
the  fact  that  in  them  certain  parts  of  the  nerve-trunks,  or  their  whole 
thickness,  is  destroyed,  to  the  most  varied  extent  and  degree,  by  the 
force  applied,  so  that  we  find  them  more  or  less  pulpy.  Under  these 
circumstances,  there  must  be  a  paralysis  corresponding  to  the  injury, 
from  which  we  determine  the  nerve  affected,  and  the  extent  of  the 
effect.  On  the  whole,  such  contusions  of  nerves  without  womids  are 
rare,  for  the  chief  nerve-trunks  lie  deep  between  the  muscles,  and  so 
are  less  apt  to  be  injured  directly. 

It  must  a  priori  be  acknowledged  that  concussion  may  affect 
other  organs  and  tissues  than  nerves,  and  induce  temporary  or  per- 
manent disturbances,  not  only  of  the  functional  but  of  the  nutritive 
processes.  Such  disturbances  may  also  have  an  important  influence 
on  the  course  of  repair  after  the  injury,  and  are  mentioned  by  some 
surgeons  as  the  chief  causes  of  inflammations  that  are  occasionally 
very  violent  and  develop  easily-decomposing  exudations  and  infiltra- 
tions. I  am  far  from  denying  the  influence  of  an  energetic  concus- 
sion on  a  bone  whose  medulla  and  vessels  are  thereby  torn,  witliout 
its  being  fractured ;  under  some  circumstances  the  results  of  such  an 
injury  might  be  more  extensive  and  tedious  than  those  of  a  fracture 
from  too  great  bending;  but  we  should  not  ascribe  the  frequent 
severity  of  the  course  of  contused  wounds  entirely  to  this  cause. 

Contusions  of  the  vessels  must  be  much  more  apparent,  since  the 
walls  of  the  smaller  vessels,  especially  of  the  subcutaneous  veins,  are 
destroyed  by  the  contusing  force,  and  blood  escapes  from  them. 
Hence,  suhcutaneous  hcamorrhage  is  the  almost  constant  consequence 
of  a  contusion.  It  would  be  much  more  considerable  if  in  this  variety 
of  injury  the  wound  of  the  vessel  had  sharp  edges,  and  gaped ;  but 
this  is  not  usually  the  case.  Contused  wounds  of  the  vessel  are 
rough,  uneven,  ragged,  and  these  iiTegularities  form  obstacles  to  the 
escape  of  the  blood ;  the  fiiction  is  so  great  that  the  pressure  of  the 
blood  is  unable  to  overcome  it ;  fibrinous  clots  form  on  these  inequal- 
ities, even  extending  into  the  calibre  of  the  vessel,  causing  mechanical 
closure  of  the  vessel,  or  thrombus.  Contusion  of  the  wall  of  a  ves- 
sel, Avith  alteration  of  its  structure,  may  alone  cause  coagulation  of 
the  blood  ;  for  Sruclce  has  proved  that  a  living,  healthy  intima  of  the 


152        CONTUSIONS  OF  THE  SOFT  PARTS  WITHOUT   WOUNDS. 

vessel  is  very  important  for  tlie  fluidity  of  the  blood  within  the  vessel. 
We  shall  again  return  to  this  subject,  under  contused  wounds.  The 
counter-pressure  of  the  soft  parts  prevents  an  excessive  escape  of 
blood  for  the  muscles  and  skin  exercise  a  natural  compression  ;  hence, 
these  subcutaneous  haemorrhages,  even  when  from  a  large  vessel  of 
the  extremities,  are  very  seldom  instantly  dangerous  to  life.  Of 
course  it  is  different  in  haemorrhages  into  the  cavities  of  the  body; 
here  there  is  little  besides  movable  parts,  that  can  offer  no  sufficient 
opposition  to  the  escape  of  the  blood ;  hence,  these  haemorrhages  are 
not  infrequently  fatal.  This  may  be  in  two  ways :  partly  from  the 
amount  of  blood  escaping — into  the  thorax  or  abdomen,  for  instance — 
partly  from  the  pressure  of  the  blood  on  the  parts  in  the  cavity — on 
the  brain,  for  instance — which  are  not  only  partly  destroyed  by  the 
blood  flowing  from  hirge  vessels,  but  are  compressed  in  various  direc- 
tions, and  their  functions  thus  impaired.  Hence,  hsemorrhages  in  the 
brain  cause  rapidly-occurring  paralyses,  and  often,  also,  disturbance 
of  the  sensorium.  In  the  brain  we  call  this  escape  of  blood,  as  well 
as  the  symptoms  induced  by  it,  apoplexy  (from  airo  and  nXrjooo)^  to 
knock  down). 

If  a  large  artery  of  an  extremity  be  contused,  the  conditions  are  the 
same  as  in  a  stitched  or  compressed  punctured  wound.  A  traumatic 
aneurism,  a  pulsating  tumor,  forms,  as  described  in  the  last  lecture. 
But  this  is  rare  as  compared  with  the  numerous  contusions  occurring 
daily,  and  is  so,  doubtless,  because  the  larger  arteries  lie  quite  deep, 
and  the  arterial  coats  are  firm  and  elastic,  so  that  they  tear  far  less 
readily  than  the  veins,  although  a  short  time  since,  in  the  clinic,  we 
saw  a  subcutaneous  rupture  of  the  anterior  tibial  artery.  A  strong, 
muscular  man  had  a  fracture  of  the  leg ;  the  skin  was  uninjured ;  the 
tibia  was  fractured  about  the  middle,  the  fibula  rather  higher.  The 
considerable  tumor  that  at  once  formed  at  the  seat  of  fracture  pulsated 
\'isibly  and  perceptibly  to  the  touch  on  the  anterior  surface  of  the  leg. 
There  was  very  evident  buzzing  sound  in  it,  which  I  was  able  to  de 
monstrate  to  the  class.  The  foot  was  dressed  with  splints  and  band 
ages  ;  we  avoided  the  application  of  an  immovable  dressing,  so  that 
we  might  watch  the  further  coaarse  of  the  traumatic  aneurism  that  had 
evidently  formed  here.  We  renewed  the  dressing  every  three  or  four 
days,  and  could  see  the  tumor  gradually  becoming  smaller  and  pulsat- 
ing less  strongly,  till  it  finally  disappeared,  a  fortnight  after  the  injm-y. 
The  aneurism  had  been  cured  by  the  compression  from  the  bandage. 
Nor  was  the  recovery  of  the  fracture  interrupted ;  eight  weeks  after 
the  injury,  the  patient  had  full  use  of  his  limb. 

The  most  frequent  subcutaneous  haemorrhages  in  contusions  are 
from  rupture  of  the  subcutaneous  veins.     These  effusions  of  blood 


CONTUSIONS  OF  BLOOD-VESSELS.  I53 

cause  visible  symptoms  which  vary,  partly  from  the  quantity  of  the 
effused  blood,  partly  from  the  distribution  of  the  blood  in  the  tissue. 
Tlie  more  vascular  a  part,  and  the  more  severely  contused,  the 
greater  the  extravasation.  The  extravasated  blood,  if  it  escapes  from 
the  vessels  slowly,  forms  a  passage-way  between  the  connective-tissue 
bundles,  especially  those  of  the  subcutaneous  connective  tissue  and 
muscles  ;  this  must  cause  infiltration  of  the  tissue  with  blood  and  con- 
sequent swelling.  Tliese  diffuse  and  subcutaneous  hjemorrhages  we 
term  suggillations  or  suffusions.  The  more  relaxed  and  yielding,  and 
the  easier  to  press  apart  the  tissue  is,  the  more  extensive  will  be  the 
infiltration  of  blood,  if  it  ffows  gradually  but  continually  from  the 
vessels  for  a  time.  Hence,  as  a  rule,  we  find  the  effusions  of  blood  in 
the  eyelids  and  scrotum  quite  extensive,  because  the  subcutaneous 
connective  tissue  there  is  so  loose.  The  thinner  the  skin,  the  more 
readily  and  quickly  we  shall  recognize  the  suggillation ;  the  blood  has 
a  blue  color  through  the  skin,  or  presses  into  it  and  gives  it  a  steel- 
blue  color.  Under  the  conjunctiva  bulbi,  on  the  contrary,  the  blood 
appears  quite  red,  as  this  membrane  is  so  thin  and  transparent. 
Blood  extravasations  in  the  cutis  itself  appear  as  red  spots  (purpura) 
or  strijB  (vibices) ;  but  in  this  form  they  are  very  rarely  due  to  contu- 
sion, they  are  caused  by  spontaneous  rupture  of  the  vessels ;  whether 
because  the  walls  of  the  vessels  are  particularly  thin  in  some  persons, 
as  in  those  abeady  mentioned  as  being  of  hfemorrhagic  diathesis,  or 
because  they  are  especially  brittle  and  tender  from  some  unknown 
condition  of  the  blood,  as  in  scorbutis,  some  forms  of  typhus,  morbus 
maculosus  Werlhofii,  etc.  Contusion  of  the  cutis  may  usually  be  rec- 
ognized by  a  very  dark-blue  color,  passing  into  brown  ;  also  by  stria- 
tion  of  the  epidermis  with  so-called  chaps,  or,  as  they  are  technically 
termed,  excoriations,  flajdng  of  the  skiru 

If  much  blood  escape  suddenly  from  the  vessels  and  be  effused  in 
the  loose  cellular  tissue,  a  more  or  less  bounded  cavity  is  formed. 
This  form  of  effusion  of  blood  is  called  ecchymosis,  ecchymo^na,  hce- 
rnatoma,  or  blood-tumor.  Whether  the  skin  be  discolored  at  the 
same  time,  depends  on  how  deep  the  blood  lies  under  it.  In  deep 
effusions  of  blood,  diffuse  as  well  as  circumscribed,  we  often  find  no 
discoloration  of  the  skin,  especially  soon  after  the  injury ;  we  only 
perceive  a  tumor  whose  rapid  development  immediately  after  an  injury 
at  once  shows  its  nature ;  this  tumor  feels  soft  and  tense.  The  cir- 
cumscribed effusion  of  blood  offers  the  very  characteristic  feeling  of 
jfuctuation.  You  may  most  readily  obtain  a  clear  idea  of  this  feeling 
by  filling  a  bladder  with  water  and  then  feeling  its  walls.  In  surgical 
practice  the  recognition  of  fluctuation  is  very  important,  for  there  are 
jinumerable  cases  where  it  is  important  to  determine  whether  we 


154        CONTUSIONS   OF   TEE   SOFT   PARTS   WITHOUT   WOUNDS. 

have  to  deal  with  a  tumor  of  firm  consistence,  or  with  one  containing 
fluid.  You  will  be  shown  in  the  clinic  how  it  is  best  to  make  this 
examination  in  different  eases. 

Some  of  these  effusions  of  blood  have  received  particular  names 
according  to  the  localities  where  they  occur.  Thus  those  coming  on 
the  heads  of  the  newly-born,  between  the  various  coverings  of  the 
skull  and  in  it,  are  called  cephalhcematoma  (from  KecpaX'}],  head,  and 
aifiarou,  to  soil  with  blood),  cephalic  tumors  of  the  newly-born.  The 
extravasations  in  the  labia  majora,  from  contusions  or  the  spontaneous 
rupture  of  distended  veins,  have  received  the  neat  name  of  episiohcema- 
toma  or  episiorrhagia  (from  eTreioiov,  tfle  external  genitals).  Effu- 
sions of  blood  in  the  pleura  and  pericardium  have  also  special  desig- 
nations :  hcematothorax,  hmmatojMrlcardium,  etc.  On  the  whole, 
we  attach  little  importance  to  these  euphonic  Latin  and  Greek  names ; 
but  you  should  know  them,  so  as  to  understand  them  when  reading 
medical  books,  and  not  seek  for  any  thing  mysterious  behind  them  ; 
also  that  you  may  use  them  so  as  to  express  yourself  quicker,  and  be 
readily  understood. 

The  subsequent  course  and  symptoms  are  very  characteristic  of 
these  subcutaneous  effusions  of  blood.  Looking  first  at  the  diffuse 
effusions  of  blood,  immediately  after  the  injury,  we  are  rarely  able  to 
decide  how  extensive  the  bleeding  has  been  or  still  is.  If  you  ex- 
amine the  contused  part  the  second  or  third  day  after  the  injury,  you 
notice  that  the  discoloration  is  more  extensive  than  on  the  first  day  ; 
this  appears  to  increase  subsequently  ;  that  is,  it  becomes  more  per- 
ceptible. The  extent  is  sometimes  astonishing.  We  once  had  in  the 
clinic  a  man  with  fractured  scapula ;  at  first  there  was  only  slight  dis- 
coloration of  the  skin,  although  there  was  a  large  fluctuating  tumor. 
On  the  eighth  day,  the  whole  back  from  the  neck  to  the  gluteal  mus- 
cles was  of  a  dark  steel-blue,  and  presented  a  peculiar,  almost  comical 
appearance,  the  skin  looking  as  if  painted.  Such  widely-spreading 
extravasations  are  particularly  apt  to  occur  in  cases  of  fractured  bones, 
especially  of  the  arm  or  leg.  But  fortunately  this  partly  dark-blue, 
partly  bluish-red  color,  along  with  which  the  skin  is  not  sensitive  and 
scarcely  swollen,  does  not  remain  so,  but  further  changes  take  place ; 
first  there  is  further  change  of  color,  the  blue  and  red  pass  into  mixed 
brown,  then  to  green,  and  finally  to  a  bright  lemon  yellow.  This  pecu- 
liar play  of  colors  has  given  rise  to  the  expression  of  "  beating  one 
black  and  blue,"  or  "  giving  one  a  black  eye."  The  last  color,  the 
yellow,  usually  remains  a  long  time,  often  for  months ;  it  finally  dis- 
appears, and  no  visible  trace  of  the  extravasation  remains. 

If  we  ask  ourselves  whence  come  these  various  colorings  of  the 
skin,  and  if  we  have  the  opportunity  of  examining  blood  extravasa- 


CONTUSIONS   OF  BLOOD-VESSELS. 


155 


tions  in  various  stages,  we  find  that  it  is  the  coloring  matter  of  the 
blood  which  gradually  passes  through  the  metamorphoses  and  shades 
of  color.  When  the  blood  has  escaped  from  the  vessels  and  entered 
the  connective  tissue,  the  fibrine  coagulates.  The  serum  enters  the 
connective  tissue,  and  thence  passes  back  into  the  vessels ;  it  is  re- 
absorbed. The  coloring  matter  of  the  blood  leaves  the  blood-corpus- 
cles, and  in  a  state  of  solution  is  distributed  through  the  tissue.  The 
fibrine  and  blood-corpuscles,  for  the  most  part,  disintegrate  to  fine 
molecules,  and  in  this  state  are  reabsorbed  by  the  vessels ;  as  in  the 
thrombus  a  few  white  blood-cells  may  attain  a  higher  development.  The 
coloring  matter  of  the  blood  which  saturates  the  tissues  passes  through 
various,  not  thoroughly  understood  metamorphoses  with  change  of 
color,  till  it  is  finally  transformed  into  a  permanent  coloring  matter, 
which  is  no  longer  soluble  in  the  fluids  of  the  body — hoeinatoidiii. 
As  in  the  thrombus,  this  is  partly  granular,  partly  crystalline ;  in  a 

piire  state  it  is  orange-colored,  and 
Fig.  38.  if  Scanty  gives  the  tissue  a  yellow- 

ish color,  if  plentiful  a  deep  orange 
hue. 

Heahsorption  of  the  extravasa- 
tion almost  always  takes  place  in 
difi'use  suggillations,  as  the  blood 
is  very  widely  distributed  through 
the  tissues,  and  the  vessels  that 
have  to  accomplish  the  reabsorp- 
tion  have  not  been  affected  by  the 
contusion  ;  it  is  the  most  desirable 
and  under  favorable  circumstances 
the  most  frequent  result  after  sub- 
cutaneous and  intermuscular  efi"usions  of  blood. 

The  case  is  difi'erent  in  circumscribed  effusions,  in  eccJiymoses. 
Here  the  first  question  is  as  to  the  extent  of  the  effusion,  then  about 
the  state  of  the  vessels  surrounding  it ;  the  more  developed  the  latter, 
the  less  they  have  been  injured  by  the  contusion,  the  more  hope  there 
is  of  early  reabsorption ;  but  its  occurrence  is  always  less  constant  in 
large  effusions  of  this  variety.  There  are  various  factors  which  inter- 
fere with  it ;  in  the  first  place,  there  is  thickening  of  the  connective 
tissue  around  the  effusion  of  blood,  as  around  a  foreign  body  (as  in 
traumatic  aneurism  also),  by  which  the  blood  is  entirely  encapsulated ; 
the  fibrine  of  the  effusion  is  deposited  in  layers  on  the  inner  surface 
of  this  sac,  the  fluid  blood  remains  in  the  middle.  Thus  the  vessels 
about  the  blood-tumor  can  take  up  very  little  fluid,  as  they- are  sepa- 
rated from  the  fluid  part  of  the  blood  by  layers  of  fibrine,  which  an. 


Granular  and  crystalline  haematoidin,  partly 
orange,  partly  ruby-red  in  color.  Magni- 
fied 400. 


156        CONTUSIONS  OF  THE  SOFT  PARTS  WITHOUT  WOUNDS. 

often  quite  tliick.  Here  we  bave  the  same  conditions  as  in  large 
fibrinous  exudations  in  the  pleura ;  there  also  the  fibrous  deposits  on 
the  walls  greatly  interfere  with  reabsorption.  This  can  only  take 
place  perfectly  when  the  fibrine  disintegrates  to  molecules,  becomes 
fluid,  and  thus  absorbable ;  or  when  it  is  organized  to  connective  tis- 
sue, and  supplied  with  blood  and  lymph  vessels.  This  is  not  so  very  rare 
in  pleuritic  deposits.  But  there  is  also  another  fate  for  such  extrava- 
sations. The  fluid  portion  of  the  blood  may  be  completely  reabsorbed, 
and  a  firm  tumor  composed  of  concentric,  onion-like  layers  may  remain. 
This  results  occasionally  from  extravasations  in  the  labia  majora ;  a  so- 
called  Jibi'ous  tumor  is  thus  formed ;  in  the  cavity  of  the  uterus,  also, 
such  fibrous  tumors  occasionally  develop.  Some  haematomata  may  be 
partly  organized  to  connective  tissue,  and  gradually  take  up  lime-salts 
and  entirely  calcify ;  a  rare  termination,  but  one  that  occurs  in  efi'u- 
gions  of  blood  in  large  goitres.  Another  mode  is  the  transformation 
of  the  blood-tumor  to  a  cyst;  this  is  seen  in  the  brain,  and  in  soft 
tumors.  Besides  other  modes  of  origin,  some  cysts  in  goitres  may  owe 
their  origin  to  such  efi"usions.  By  a  cyst  or  encysted  tumor  we  mean 
sacs  or  bags  containing  more  or  less  fluid.  The  contents  of  these 
cysts,  resulting  from  extravasation  of  blood,  are  darker  or  lighter  ac- 
cording to  their  age ;  indeed,  the  blood-red  may  totally  disappear 
from  them,  and  the  contents  become  quite  clear  or  only  slightly 
clouded  by  fat  molecules.  In  large  circumscribed  extravasations  you 
will  find  numerous  and  beautifully-formed  hematoidin  crystals  more 
rarely  than  in  small  difixise  ones,  for  in  the  former  fatty  disintegration 
of  the  elements  of  the  blood  predominates,  hence  excretion  of  choles- 
terine  crystals  is  more  common  in  them.  The  capsule  enclosing  these 
old  efi'usions  arises  partly  from  organization  of  the  peripheral  parts 
of  the  blood-clot,  partly  from  the  circumjacent  tissue. 

jSiqypuration  of  circumscribed  extravasations  is  far  more  frequent 
than  the  two  last  described  metamorphoses,  but  is  not  so  common  as 
reabsorption.  The  inflammation  in  the  vicinity,  and  the  plastic  pro- 
cess in  the  peripheral  part  of  the  extravasation,  from  which,  in  the 
two  preceding  cases,  the  thickened  connective  tissue  was  developed, 
which  encapsulated  the  blood,  assume  a  more  acute  character  in  the 
case  we  are  about  to  speak  of;  a  boundary  layer  is  formed  here  also, 
but  not  slowly  and  gradually  as  in  the  preceding  cases,  but  by  rapid 
cell-formation  ;  plastic  infiltration  of  the  tissue  does  not  lead  to  devel- 
opment of  connective  tissue,  but  to  suppuration ;  the  inflammation 
after  a  time  attacks  the  cutis,  and  it  suppurates  from  within  outward, 
and  is  finally  perforated,  and  the  pus  mixed  with  blood  is  evacuated ; 
the  walls  of  the  cavity  come  together,  cicatrize  and  grow  together, 
and  healing  thus  takes  place.     We  shall  speak  more  exactlv  of  this 


CONTUSIOXS  OF  BLOOD-YESSELS.  157 

mode  of  healing  when  treating  of  abscess ;  we  call  any  pus-tumor, 
i.  e.,  circumscribed  collection  of  pus  under  the  skin  at  any  depth,  an 
abscess :  hence  we  term  the  above  process  the  conversion  of  an  ex- 
travasation of  blood  into  an  abscess.  This  process  may  be  very  pro- 
tracted, it  may  last  three  or  four  weeks,  but,  if  not  dangerous  from  its 
location,  it  generally  runs  a  favorable  course.  We  recognize  the  sup- 
puration of  an  extravasation  of  blood  by  the  increasing  inflammatory 
redness  of  the  skin,  the  growth  of  the  tumor,  increasing  pain,  occasion- 
ally accompanied  by  fever,  and  finall}^  by  thinning  of  the  skin  at  some 
point,  where  it  is  finally  perforated. 

Lastly,  there  may  be  rapid  decomposition  of  the  extravasation ; 
fortunately,  this  is  rare.  Then  the  tumor  grows  hot,  tense,  and  very 
painful,  the  fever  usually  becomes  considerable,  chills  and  other  severe 
general  symptoms  may  occur.  This  termination  is  the  worst,  and  the 
only  one  that  requires  speedy  relief. 

^Tiether  there  shall  be  reabsorption,  suppuration,  or  putrefaction 
of  an  extravasation,  depends  not  only  on  the  amount  of  the  effused 
blood,  but  very  much  on  the  grade  of  the  contusion  that  the  tissues 
have  suffered ;  as  long  as  these  may  return  to  their  normal  state,  re- 
absorption  will  be  probable ;  if  the  tissues  be  broken  down  and  pass 
into  disintegration  or  decomposition,  they  will  induce  suppuration  oi 
decomposition  of  the  blood ;  briefly,  the  effused  blood  will  have  the 
same  fate  as  the  contused  tissue. 

While  the  skin  is  uninjured  we  cannot  judge  accurately  how  much 
the  muscles,  tendons,  and  fascias,  are  injured ;  occasionally  the  size  of 
the  extravasation  may  give  some  aid  on  this  point,  but  it  is  a  very 
uncertain  measure ;  it  is  better  to  test  the  amount  of  functional  ac- 
tivity of  the  affected  muscles,  but  even  the  results  thus  given  must  be 
carefully  accepted ;  the  amount  of  force  that  has  acted  on  the  part 
may  lead  to  an  approximate  estimation  of  the  existing  subcutaneous 
destruction.  In  contusion  of  muscles,  as  in  wounds,  healing  takes 
place  from  the  crushed  mviscular  elements  undergoing  molecular  disin- 
tegration and  being  absorbed,  or  by  being  eliminated  with  the  pus  on 
suppuration  of  the  extravasation,  but  then  there  is  new  formation  both 
of  connective  tissue  and  muscle. 

The  largest  extravasations,  either  diffuse  or  circumscribed,  are 
usually  accompanied  by  injuries  of  the  bones ;  but  it  will  be  better  to 
consider  the  injury  of  the  bone  in  a  separate  section. 

If  a  portion  of  the  body  be  so  crushed  as  4o  be  entirely  or  mostly 
incapable  of  living,  it  becomes  cold,  bluish  red,  brownish  red,  then 
black ;  it  begins  to  putrefy ;  the  products  of  putrefaction  enter  the 
neighboring  tissues  and  the  blood ;  the  local  inflammations,  as  Avell  as 
the  fever,  assume  peculiar  forms.  As  this  is  the  same  in  contusions 
with  or  without  wounds,  we  shall  speak  of  it  later. 


158         CONTUSIONS   OF  THE   SOFT   PARTS  WITHOUT   WOUNDS. 

[During  the  operation  for  castration,  when  the  cord  and  its 
nerves  are  ligated,  even  under  chloroform,  we  may  notice  excessive 

nervous  effect. 

In  Golz's  experiment  of  slapping  a  frog  on  the  belly,  the  animal 
falls  at  once  into  collapse,  and  may  even  die  from  paralysis  of  the 
heart  and  consequent  cerebral  anaemia  ;  venous  blood,  being  no  longer 
drawn  in  by  the  heart,  collects  in  the  large  abdominal  veins,  which 
become  distended  while  the  lungs  and  brain  receive  no  more  blood. 
This  impairment  of  the  heart's  function  is  referred  to  reflex  action. 
Irritation  of  a  sensitive  nerve  may  induce  not  only  temporary  retarda- 
tion of  the  heart's  action,  but  acute  cerebral  anasmia.  This  may  be 
shown  by  the  following  easy  experiment  :  Fasten  a  rabbit  in  proper 
position  and  pass  a  long  slender  needle  through  the  thorax- wall  into 
the  heart,  then  we  may  judge  of  the  heart's  action  by  the  move- 
ments of  the  needle,  this  forming  a  lever  with  a  long  handle.  The 
animal  bears  the  operation  well,  and  in  a  short  time  the  pulsations 
become  regular.  If  we  now  approach  some  irritating  substance,  as 
chloroform  or  ammonia,  to  the  nose  of  the  animal,  the  pulsations 
will  be  temporarily  arrested  and  then  will  be  slower  and  longer, 
showing  retardation  of  the  heart's  action.  This  experiment  may 
be  often  repeated  ;  it  shows  that  simple  irritation  of  the  trigeminus 
filaments  suffices  to  induce  retardation  of  the  heart's  action,  which 
in  its  turn  is  followed  by  cerebral  anosmia  due  to  contraction  of  the 
cerebral  capillai'ies.  What  in  the  rabbit  is  caused  by  irritation  of 
the  trigeminus  is  produced  in  man  by  irritating  any  nerve  of  sen- 
sation. Perhaps  we  may  thus  explain  some  cases  of  faintness,  end- 
ing in  death,  which  occur  after  severe  pain.  Those  persons  appear 
particularly  prone  to  faint,  that  restrain  all  exhibition  of  pain  ;  while 
crying,  struggling,  etc.,  by  increasing  the  number  and  depth  of  the 
respirations  and  hastening  the  circulation,  unintentionally  but  ef- 
fectively tend  to  prevent  retardation  of  the  heart's  action  and 
cerebral  anaemia. 

Besides  the  effect  of  the  contusion  on  the  nerves,  which  we 
usually  recognize  only  from  the  symptoms,  there  are  important 
anatomical  changes.  To  study  these  experimentally,  contusions 
have  been  induced  in  parts  of  animals  which  had  been  rendered 
bloodless,  otherwise  extravasations  from  the  ruptured  vessels  would 
prevent  microscopical  examination.  Varied  as  may  be  the  force 
causing  the  injury,  the  variation  shown  by  the  injured  tissue  is 
slight,  except  in  the  vessels.  Gussenhauer,  in  slight  contusions, 
found  almost  exclusively  ruptures  in  the  loose  connective  tissue 
accompanying  the  smaller  blood-vessels ;  where  the  force  was 
greater,  there  was  also  solution  of  continuity  of  the  intercellular 


CONTUSIONS   OF   BLOOD-VESSELS.  I59 

substance  of  the  tissue,  while  the  cellular  and  fibrous  parts  of  the 
tissue  were  more  or  less  seiaarated  ;  the  muscular  filaments  were  in 
many  places  bent  or  torn,  with  the  contractile  substance  here  and 
there  escaping  from  the  ruptures  of  the  sarcolemma.  Even  where 
the  tissue  was  entirely  mashed,  the  cellular  elements,  connective- 
tissue  corjiuscles,  cells  of  the  walls  of  the  vessels,  endothelium,  etc., 
were  usually  preserved,  the  destruction  affecting  chiefly  the  inter- 
cellular substance  ;  even  in  organs  where  it  is  scanty  there  is  solution 
of  continuity  between  the  cells,  but  they  were  themselves  well 
preserved.  The  idea  that  in  crushed  tissue  every  structure  is  un- 
recognizable is  wholly  incorrect.  Hence  it  is  not  possible  to  make 
several  distinct  grades  with  special  anatomical  characteristics  ;  in 
bloodless  tissues  the  changes,  corresponding  to  the  injury,  only  vary 
in  grade,  or  rather  in  extent. 

The  two  most  important  signs  of  extravasation  in  contusions 
are  the  color  of  the  covering  and  swelling  of  the  part.  We  have 
already  spoken  of  the  shade,  between  red  and  violet,  induced  by 
the  vicinity  of  the  blood,  and  we  shall  hereafter  treat  of  the  subse- 
quent change  of  shade.  Swelling  of  the  contused  part  depends, 
first,  on  the  presence  of  blood  extravasation,  and  also  on  the  escape 
of  lymph  from  the  vessels  and  tissues.  The  greater  the  amount  of 
blood  escaped  the  larger  the  swelling.  But  between  the  swelling 
and  color  there  is  some  contrast,  for  with  intense  coloration  there  is 
rarely  much  swelling,  and  the  reverse.  This  is  because  the  consid- 
erable swelling  is  induced  by  rupture  of  large  vessels  which  lie 
deeply,  and  in  such  cases  the  escaped  blood  only  shows  dimly 
through  the  coverings.  The  shape  of  the  swelling  may  give  some 
idea  of  the  blood  extravasation  ;  a  regular  increase  of  volume  indi- 
cates haemorrhngic  infiltration,  an  irregular  one  a  large  effusion  in  a 
cavity,  a  hiematoma  or  blood-tumor.  In  the  highest  grade  of  con- 
tusion, where  the  soft  parts  have  been  crushed,  they  often  appear 
as  a  shapeless  mass,  enclosed  by  the  skin  as  in  a  bag,  in  which  cir- 
culation has  ceased. 

Extravasations,  instead  of  being  composed  of  blood,  may  in 
some  rare  cases  be  of  pure  lymph  ;  these  enlarge  slowly,  lack  the 
discoloration  and  symptoms  of  coagulation  of  the  blood  ;  on  punc- 
ture there  escapes  a  lemon-colored  clear  fluid,  like  that  of  a  hydro- 
cele ;  their  prognosis  and  treatment  differ  essentially  from  those  of 
blood-tumor.  They  are  reabsorbed  with  difficulty  if  at  all.  They 
remain  fluid  for  months,  because  they  contain  no  fibrine,  and  coagu- 
lation of  the  extravasation  is  the  first  step  toward  reabsorjDtion. 
But,  on  the  other  hand,  effusions  of  lymph  do  not  induce  suppura- 
tion or  decomposition,  so  their  prognosis  is  not  unfavorable.] 


160        CONTUSIONS   OF  THE   SOFT   PARTS   WITHOUT   WOUNDS. 

The  treatment  of  contusions  without  wound  has  for  its  object  the 
conduction  of  the  process  to  the  most  favorable  termination  possible, 
that  is,  to  reabsorption  of  the  extravasation ;  when  this  takes  place, 
the  injuries  to  the  other  soft  parts  also  progress  favorably,  as  the  whole 
process  remains  subcutaneous.  We  here  refer  solely  to  those  cases 
where  the  contusion  of  the  soft  parts  and  the  extravasation  are  the 
only  objects  of  treatment;  where  the  bone  is  broken  it  shoxild  be 
treated  first  of  all,  the  extravasation  of  itself  would  scarcely  be  an  ob- 
ject for  special  treatment.  If  called  to  a  contusion  that  has  just  oc- 
curred, the  indication  may  be  to  arrest  any  still  continuing  ha3mor- 
rhage ;  this  is  best  done  by  compression,  which,  where  convenient,  is  to 
be  made  by  evenly-applied  bandages.  In  North  Germany,  when  a 
child  falls  on  its  head,  or  knocks  its  forehead,  the  mother  or  nurse  at 
once  presses  the  handle  of  a  spoon  on  the  injured  spot  to  prevent  the 
formation  of  a  blood-bruise.  This  is  a  very  suitable  popular  remedy ; 
by  the  instantaneous  compression  the  further  escape  of  blood  is  hin- 
dered, as  is  also  its  collection  at  one  point,  because  it  is  compelled  by 
the  pressure  to  distribute  itself  in  the  surrounding  tissue ;  an  ecchy- 
mosis  just  forming  may  thus  be  transformed  into  a  suggillation,  so  that 
the  blood  may  more  readily  be  absorbed.  You  may  occasionally  at- 
tain the  same  object  by  a  well-applied  bandage. 

But  we  rarely  see  the  injury  so  early,  and  in  the  great  majority 
of  cases  there  is  also  an  injury  of  a  bone  or  joint,  and  the  treatment 
of  the  blood-extravasation  is  a  secondary  object. 

The  use  of  cold,  in  the  shape  of  bladders  or  rubber  bags  filled  with 
ice,  or  of  cold  lotions,  to  which  it  is  an  old  custom  to  add  vinegar  or 
lead-water,  is  resorted  to  as  a  remedy  in  recent  contusions ;  it  is 
said  to  prevent  excessive  inflammation.  But  you  must  not  rely  too 
much  on  these  remedies ;  the  means  that  most  aids  the  reabsorption 
of  blood  extravasations  is  regular  compression  and  rest  of  the  part. 
Hence  it  is  best  to  envelop  the  extremities  in  moist  bandages,  and 
over  them  apply  wet  cloths,  which  are  to  be  renewed  every  three  or 
four  hours.  Other  remedies,  winch  usually  act  well  in  inflammations 
of  the  skin,  such  as  mercurial  ointment,  are  of  little  use  here.  But  I 
must  not  forget  arnica ;  this  remedy  is  so  honored  by  some  families 
and  physicians  that  they  would  consider  it  unpardonable  to  neglect 
prescribing  lotions  of  infusion  of  arnica,  or  of  Avater  with  the  addition 
of  tincture  of  arnica.  Faith  is  mighty ;  one  beheves  in  arnica,  an- 
other in  lead-water,  a  third  in  vinegar,  as  the  potent  external  reab- 
sorbent.  In  all  cases  the  eff"ect  is  doubtless  simply  due  to  the  moist- 
ure and  the  variation  of  temperature  of  the  skin  caused  by  the  com- 
press, whereby  the  capillaries  are  kept  active,  now  brought  to  contrac- 
tion, now  to  dilatation,  and  thus  placed  in  a  better  state  for  reabsorp- 
tion because  thev  are  active. 


TREATMENT   OF  BLOOD-EXTRAVASATIONS.  161 

Diffuse  blood-extravasations  of  the  skin  with  moderate  contusion 
of  the  soft  jDarts  are  usually  absorbed  without  much  treatment.  If  a 
circumscribed  extravasation  does  not  change  considerably  in  the  course 
of  a  fortnight,  there  is  nevertheless  no  indication  for  further  interfer- 
ence. We  then  paint  the  swelling  once  or  twice  daily  with  dilute 
tincture  of  iodine,  compi-ess  it  with  a  suitable  bandage,  and  not  unfre- 
quently  see  the  swelling  gradually  subside  after  several  weeks. 
Should  it  become  hot,  and  the  skin  over  it  grow  red  and  painful,  we 
must  expect  suppuration ;  then  even  the  continued  application  of  cold 
will  rarely  change  the  course,  though  it  may  alleviate  it.  Then,  in 
order  to  hasten  the  termination  of  the  suppuration,  which  cannot  be 
avoided,  we  may  apply  warm  fomentations,  either  simply  of  folded 
muslin  wet  with  warm  water  or  cataplasms;  now  you  quietly  await 
the  further  course ;  if  the  general  health  be  not  impaired,  but  the  pa- 
tient feels  pretty  well,  you  calmly  await  perforation ;  it  will  perhaps 
be  weeks  before  the  skin  gradually  becomes  thinner  at  some  point 
and  finally  opens,  the  pus  is  evacuated,  the  walls  of  the  large  cavity 
fall  together,  and  in  a  short  time  the  parts  are  all  healed.  At  the 
commencement  of  this  lecture  I  mentioned  a  case  where,  with  a  frac- 
tured scapula,  there  was  an  enormous  partly  diffuse,  partly  circum- 
scribed exti'avasation  ;  here  there  was  a  strongly-fluctuating  tumor, 
which  was  not  reabsorbed,  while  the  diffuse  effusion  was  rapidly  re- 
moved ;  the  suppuration  did  not  end  in  perforation  till  the  fifth  week, 
then  one  and  a  half  to  two  quarts  of  pus  were  evacuated ;  a  week 
later  this  enormous  cavity  was  healed,  and  the  patient  left  the  hospi- 
tal well.  Why  we  do  not  here  interfere  earlier  and  aid  Nature  by  an 
incision,  we  shall  consider  more  closely  when  we  treat  of  abscesses. 

Should  the  tension  of  the  swelling  rapidly  increase,  however,  dur- 
ing the  suppuration  of  the  extravasation,  and  high  fever  with  chills 
occur,  we  may  suppose  that  the  blood  and  pus  are  decomposing,  that 
there  is  putrefaction  of  the  enclosed  fluid.  Fortunately,  this  is  rare, 
and  occurs  almost  exclusively  where  there  is  gTcat  crushing  of  the 
muscles  or  splintering  of  the  bone.  With  such  symptoms  of  course 
the  putrid  fluid  should  be  quickly  evacuated ;  then  you  should  make 
a  large  incision  through  the  skin,  unless  this  be  forbidden  by  the  ana- 
tomical position  of  the  parts ;  in  which  case  several  small  incisions 
should  be  made  at  points  where  the  fluid  may  escape  freely  and  easily. 
[You  now  have  a  cavity  filled  with  granulations  and  containing  de- 
composed pus  and  broken-down  blood-clots.  To  disinfect  this, 
carefully  empty  out  the  contents  and  cleanse  the  sac  with  a  two-  to 
four-per-cent.  solution  of  carbolic  acid  and  dry  sponges,  then  apply 
a  five-per-cent.  solution  of  chloride  of  zinc,  introduce  a  drainage- 
tube,  and  put  on  a  Lister^s  dressing. 
12 


162         CONTUSIONS   OF  THE   SOFT  PARTS  WITHOUT   WOUNDS. 

Generally,  after  free  opening,  cleansing,  and  disinfecting,  the 
cavity  heals  rapidly,  the  walls  being  already  partly  covered  with 
granulations  which,  under  the  compression,  unite  and  melt  together. 

We  should  mention  that,  in  case  of  extensive  mortification  of 
the  soft  parts  after  such  injuries,  amputation  may  be  indicated,  but 
this  is  rare  unless  there  was  at  the  same  time  fracture  of  the  bone. 

Although  the  sacs  of  blood  extravasations  rarely  require  open- 
ing, it  is  moi'e  frequent  with  those  containing  lymph,  not  on  account 
of  suppuration,  but  to  induce  healing  ;  as  they  do  not  coagulate  or 
absorb,  but  often  increase  in  size,  operation  is  required  in  most 
cases,  and  it  is  advisable  not  merely  to  puncture  the  tumor  and 
evacuate  the  contents,  but  to  open  it  widely,  disinfect,  and  drain  it 
as  above  described.] 


CHAPTER  IV. 

CONTUSED  AND  LACEEATJED    WOUNDS    OF  TUB 
SOFT  PABTS. 


LECTURE    XII, 


Mode  of  Occurrence  of  these  Wounds  ;  their  Appearance. — Slight  Haemorrhage  in  Cou. 
tused  "Wounds. — Early  Secondary  Haemorrhages. — Gangrene  of  the  Edges  of  the 
Wound. — Influences  that  effect  the  Slower  or  more  Eapid  Detachment  of  the  Dead 
Tissue. — Indicfitions  for  Primary  Amputation. — Local  Complications  in  Contused 
Wounds ;  Decomposition,  Putrefaction,  Septic  Inflammations, — Contusion  of  Ar- 
teries ;  Late  Secondary  Hemorrhages. 

The  causes  of  contused  wounds,  of  Avliicli  we  have  to  treat  to-day, 
are  the  same  as  those  of  simple  contusions,  only  in  the  fii'st  cases  the 
force  is  usually  greater  than  in  the  latter,  or  the  body  by  which  they 
are  induced  is  of  such  a  form  as  to  di\dde  the  skin  and  soft  parts 
easily,  or  else  parts  of  the  body  have  been  injured  where  the  skin  is 
particularly  thin,  or  lies  over  parts  unusually  firm. 

The  kick  of  a  horse,  blow  from  a  stick,  bite  of  an  animal  or  a  man, 
being  run  over,  wounding  with  blunt  knives,  saws,  etc.,  are  frequent 
causes  of  contused  wounds.  Nothing,  however,  causes  more  contused 
wounds  than  rapidly-moving  wheels  and  rollers  of  machinery,  cutting- 
machines,  circular-saws,  spinning-jennies,  and  the  various  macliines 
with  cog-wheels  and  hooks.  All  of  these  instruments,  the  product 
of  advancing  industry,  do  much  injury  among  the  operatives.  Men 
and  women,  adults  and  children,  with  crushed  fingers,  mashed  hands, 
ragged,  lacerated  wounds  of  the  forearm  and  ann,  are  now  among  the 
constant  patients  in  the  surgical  wards  of  hospitals  in  every  large 
city.  Innumerable  persons  are  thus  maimed  of  fingers,  hands,  or 
arms,  and  many  of  these  patients  die  as  a  result  of  their  injuries.  If 
to  these  you  add  (what  recently  is  becoming  rarer,  it  is  true)  railroad 
injuries,  those  caused  by  blasting,  building  tunnels,  etc.,  vou  mav 


164  APPEARANCE  OF  CONTUSED  WOUNDS. 

imao-ine,  not  only  how  much  sweat,  but  how  much  blood,  clings  to  the 
many  evidences  of  modern  culture.  At  the  same  time  it  is  not  to  be 
denied  that  the  chief  cause  of  these  accidents  is  the  carelessness, 
often  the  foolhardiness,  of  the  workman.  Familiarity  with  the  dan- 
gerous object  renders  persons  at  last  careless  and  rash ;  some  pay  for 
this  with  their  lives. 

Gunshot  wounds  also  essentially  belong  to  contused  wounds ;  but, 
as  they  have  some  pecuharities  of  their  own,  we  shall  treat  of  them 
in  a  special  chapter.  Lacerated  wounds,  and  tearing  out  of  pieces 
from  the  limbs,  we  shall  consider  at  the  end  of  this  chapter. 

Fractures  of  bones  of  the  most  varied  and  dangerous  varieties  ac- 
company contused  wounds  from  all  the  above  causes ;  but  for  the 
present  we  shall  leave  these  out  of  consideration,  and  treat  only  of  the 
soft  parts. 

In  most  cases,  the  appearance  of  a  wovmd  indicates  whether  it  was 
due  to  incision  or  contusion.  You  already  know  the  character  of  in- 
cised wounds,  and  I  have  alluded  to  some  cases  where  a  contused 
wound  had  the  appearance  of  an  incised  one,  and  the  reverse.  Con- 
tused wounds,  like  incised,  may  be  accompanied  by  loss  of  substance, 
or  there  may  be  simply  solution  o'f  continuity.  The  borders  of  these 
wounds  are  generally  uneven,  especially  the  edges  of  the  skin ;  the 
muscles  occasionally  look  as  if  chopped ;  tags  of  the  soft  parts,  of 
various  sizes,  not  unfi-equently  large  flaj^s,  hang  in  the  wound,  and 
may  have  a  bluish-red  color,  from  the  blood  stagnated  or  effused  in 
them.  Tendons  are  torn  or  pulled  out,  fasciae  are  torn,  the  skin,  for 
some  distance  around  the  wound,  is  not  unfrequently  detached  from 
the  fascia,  especially  if  the  contusing  force  was  combined  with  a  tear- 
ing and  twisting.  The  grade  of  this  destruction  of  the  soft  parts  of 
course  varies  greatly,  and  its  extent  cannot  alwa^'^s  be  accurately  de- 
termined, as  we  cannot  always  see  how  far  the  contusion  and  tearing 
extend  beyond  the  wound ;  from  the  subsequent  course  of  the  wound 
we  often  satisfy  ourselves  that  the  contusion  extended  much  further 
than  the  size  of  the  wound  indicated ;  that  separation  of  muscles,  di- 
visions of  fasciffi,  and  effusions  of  blood,  extended  under  the  skin, 
which  may  have  been  but  little  torn.  It  is  unfortunate  that  the  skin- 
wound  gives  no  means  of  judging  of  the  extent  and  depth  of  the  con- 
tusion, for  it  renders  it  very  difficult  to  correctly  estimate  such  an  in- 
jury at  the  first  examination;  while  the  appearance  of  the  wound 
gives  the  laity  no  idea  of  danger,  the  experienced  surgeon  soon  sees 
the  gravity  of  the  case. 

Since  the  injury,  especially  when  due  to  machinery,  is  very  rapidly 
done,  the  pain  is  not  great;  and  immediately  after  the  injury  the  pain 
from  contused  wounds  is  often  very  slight ;  the  more  so,  the  greater 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.     165 

the  injury  and  crushing-  of  the  parts.  This  is  readily  explained  by 
the  nerves  in  the  wound  beinw-  entirely  mashed  and  destroyed,  conse- 
quently incapable  of  conducting;  moreover,  what  I  told  you  in  the 
last  lecture  about  local  concussion  of  nerves,  the  so-called  stupor  of 
the  injured  part,  comes  into  play. 

At  first  sight  it  seems  rather  remarkable  that  these  contused 
wounds  bleed  little,  if  any,  even  if  large  veins  or  arteries  be  crushed 
or  torn.  There  are  well-observed  cases  to  show  that,  after  complete 
crusliing  of  the  femoral  or  axillary  artery,  there  vrds  absolutely  no 
primary  haemorrhage.  It  is  true,  this  is  rare ;  in  many  cases  where  there 
is  complete  solution  of  continuity  of  a  large  artery  by  a  contusion, 
although  there  is  no  spirting  stream,  there  is  constant  trickling  of 
blood ;  this,  coming  from  the  femoral  artery,  would  speedily  cause 
death.  I  have  already  told  you  how  this  arrest  of  haemorrhage  takes 
place  in  small  arteries,  but  will  make  it  clearer  to  you  by  an  illustra- 
tion. A  railroad  hand  was  run  over  by  a  locomotive,  so  that  the 
wheel  passed  over  his  left  thigh  just  below  the  hip-joint.  The  unfor- 
tunate was  at  once  brought  on  a  litter  to  the  hospital ;  meantime  he 
had  lost  much  blood,  and  came  in  very  pale  and  aneemic,  but  perfectly 
conscious.  After  complete  removal  of  the  torn  clothing,  we  found  a 
horrible  mangling  of  the  skin  and  muscles.  The  bone  was  crushed  to 
atoms,  the  muscles  were  partly  mashed  to  pulp,  partly  hung  in  tags 
from  the  wound,  the  skin  was  torn  up  as  far  as  the  hip-joint.  At  no 
point  of  this  horrible  wound  did  an  artery  spirt,  but  from  the  depth  con- 
siderable blood  constantly  trickled  out,  and  the  general  state  of  the  pa- 
tient clearly  showed  that  he  had  ah'cady  lost  much  blood.  It  was  evident 
that  the  only  thing  to  be  done  here  was  to  amputate  at  the  hip-joint, 
but  in  the  condition  the  patient  then  was,  this  was  not. to  be  thought 
of;  the  new  loss  of  blood  from  this  severe  operation  would  undoubt- 
edly have  been  at  once  fatal.  Hence  it  was,  first  of  all,  necessary  to 
arrest  the  haemorrhage,  which  evidently  came  from  a  rupture  of  the 
femoral  artery.  I  first  tried  to  find  the  femoral  in  the  wound,  while  it 
was  compressed  above  ;  but  all  the  muscles  were  so  displaced,  all  the 
anatomical  relations  were  so  changed,  that  this  was  not  quickly  done, 
hence  I  proceeded  to  ligate  the  artery  below  Poupart's  ligament. 
After  this  was  done,  most  of  the  bleeding  ceased,  but  not  entirely,  on 
account  of  the  free  arterial  anastomosis ;  and  as  no  regular  dressing 
could  be  applied,  on  account  of  the  existing  mangling,  I  surrounded 
the  limb  firmly  with  a  tourniquet,  close  below  where  I  proposed 
to  exarticulate.  Now  the  bleeding  stopped;  we  gave  various 
remedies  to  re\avify  the  patient ;  wine,  w^arm  drinks,  etc.,  were  ad- 
ministered, so  that,  toward  evening,  he  had  so  far  recovered  that  hi? 
temperature  was  again  normal,  and  the  radial  pulse  was  again  good 


16Q  HAEMORRHAGE  FROM  CONTUSED  WOUNDS. 

I  should  have  preferred  postponing  the  operation  till  the  following 
day,  if,  in  spite  of  ligature  and  tourniquet,  with  the  strengthening  of 
the  heart's  beat,  there  had  not  been  some  bleeding  from  the  wound,  so 
that  I  feared  the  patient  might  bleed  to  death  during  the  night. 
Hence,  with  the  able  help  of  my  assistants,  I  exarticulated  the  thigh 
as  rapidly  as  possible.  During  the  operation  the  absolute  loss  of 
blood  was  not  great,  but  it  was  too  much  for  the  already-debilitated 
patient.  At  first  all  seemed  to  go  well ;  the  spirting  vessels  were  all 
ligated,  the  wound  cleansed,  and  the  patient  placed  in  bed ;  soon  he 
suffered  from  restlessness  and  dyspnoea,  which  increased,  finally  con- 
vulsions occurred,  and  the  patient  expired  two  hours  after  the  opera- 
tion. Examination  of  the  femoral  artery  of  the  crushed  extremity 
showed  the  following :  In  the  upper  third  of  the  thigh  there  was  a 
crushed  and  torn  part,  comprising  about  one-third  the  calibre  of  the 
artery.  The  tags  of  the  tunica  intima,  as  well  as  the  other  coats  of 
vessel,  and  the  connective  tissue  of  the  sheath,  had  rolled  up  into  the 
calibre  of  the  artery,  and  the  blood  could  only  escape  slowly ;  the 
surrounding  tissue  was  completely  saturated  with  blood.  In  this  case, 
no  clot  had  formed  in  the  artery,  as  the  escape  of  blood  was  still  too 
free  to  permit  this  ;  but,  if  you  imagine  that  the  contusion  had  affected 
the  entire  circumference  of  the  artery,  you  may  understand  how  the 
tags  of  the  coats  of  the  vessel  pressing  into  its  calibre  from  all  sides 
might  have  rendered  the  escape  of  the  blood  more  difficult,  or  even 
impossible ;  then  a  thrombus  would  have  formed,  and  stopped  the 
vessel,  and  gradually  have  become  organized,  so  as  to  cause  permanent 
closure,  just  as  after  ligation.  If  no  haemorrhage  had  followed  the  partial 
crushing  of  the  artery  in  this  case,  if,  for  instance,  the  crushing  had 
occurred  without  an  external  wound,  possibly  a  clot  would  simply  have 
formed  at  the  part  roughened  by  the  contusion,  a  thrombus  forming 
from  the  wall ;  in  this  case  there  might  have  been  crushing  of  the 
artery  with  preservation  of  its  calibre,  a  result  that  is  said  to  have 
been  observed. 

If  you  apply  the  above-described  condition  of  a  large  crushed  ar- 
tery to  smaller  arteries,  you  will  understand  how  there  may  here  more 
readily  be  complete  spontaneous  plugging  of  the  calibre  of  the  vessels 
partly  by  in-rolling  of  the  fragile,  torn  tunica  intima,  partly  by  con- 
traction of  the  tunica  muscularis  and  by  the  tags  of  the  adventitia, 
and  that  consequently  bleeding  may  fail  almost  entirely  in  such  con- 
tused wounds. 

Observation  of  this  led  a  French  surgeon,  Chassaignac^  to  invent 
an  instrument  for  crushing  off  portions  of  the  body ;  he  terms  this 
operation  ecrasement,  the  instrument  he  calls  an  'ecraseiir.  It  con- 
sists of  a  strong  metallic  ligature,  composed  of  small  links,  which 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.     167 

IS  to  be  applied  around  the  part  to  be  removed,  and  then  drawn  slow- 
ly into  a  strong  metal  frame  by  means  of  a  ratch  arrangement. 
When  the  instrument  is  properly  used  it  causes  absolutely  no  hsemor- 
rhage.  Little  favor  as  the  instrument  at  first  found  among  surgeons, 
from  their  dislike  to  contused  wounds  in  operative  surgery,  there  is 
no  doubt  of  its  advantages  in  suitable  cases.  Wounds  caused  by 
ecrasement  usually  heal  with  very  little  local  or  general  reaction  ;  co- 
incident inflammations  occur  less  frequently  with  this  class  of  wounds 
than  ^vith  pure  incised  wounds.  Nevertheless  ecrasement  will  always 
be  limited  to  a  small  number  of  operations. 

There  is  another  factor  for  limiting  the  haemorrhages  in  extensive 
contusions,  that  is,  the  weakening  of  the  heart's  action  caused  by  the 
injury,  probably  due  to  reflex  action.  Persons  badly  injured,  besides 
Bufl'ering  from  loss  of  blood  and  injury  of  the  nerve-centres,  are  usually 
for  a  time  in  a  state  of  numbness  or  stupor ;  the  word  most  common!}' 
used  to  express  this  state  of  depression  is  "  shock."  The  fi-ight  from 
the  injury  and  all  thoughts  about  it,  which  follow  in  rapid  succession, 
unite  in  producing  great  psychical  depression,  which  has  a  paralyzing 
effect  on  the  heart's  action.  Still,  even  in  persons  not  greatly  af- 
fected psychically  by  the  injury,  as  old  soldiers  who  have  often  been 
■wounded,  or  very  phlegmatic  persons,  a  severe  injury  is  not  entirely 
without  this  effect,  so  that  we  must  suppose  that  there  are  purely 
physical  causes  for  shock.  Contusions  of  the  abdomen  have  an  even 
more  depressing  effect  on  the  nerve-centres  than  do  those  of  the  ex- 
tremities, as  I  have  already  told  you.  In  this  connection  the  so-called 
beating-experiment  (Klopfversuch)  of  Golz  is  very  interesting:  if  we 
repeatedly  strike  a  frog  sharply  on  the  belly  with  the  handle  of  a 
scalpel,  he  becomes  as  it  were  paralytic ;  as  a  result  of  paresis  of  their 
walls,  the  abdominal  vessels  distend  greatly  and  take  up  almost  all  the 
blood,  so  that  all  the  other  vessels  and  even  the  heart  become  blood- 
less, and  the  latter  only  contracts  feebly. 

When  the  patient  has  recovered  from  this  state  of  psychical  and 
physical  depression,  the  heart  begins  to  act  with  its  former  or  even 
greater  energy,  then  hfemorrhages  may  occur  from  vessels  that  had  not 
previously  bled.  This  variety  of  secondary  haemorrhage  occurs  after 
operations,  when  the  effect  of  the  anaesthetic  has  passed  off.  Hence 
the  patient  should  be  carefully  watched  at  this  time,  to  guard  against 
such  secondary  haemorrhages,  especially  if,  from  the  locality  of  the  in- 
jury, there  be  reason  to  suspect  that  a  large  artery  has  been  injured. 

Now  we  must  again  examine  somewhat  more  attentively  the  local 
changes  in  the  wound. 

Although  doubtless  the  processes  that  take  place  in  the  contused 
wound,  the  changes  on  its  surface  and  final  healing,  must  be  essentiall_y 
the  same  as  in  incised  wounds,  still  in  the  appearances  in  the  two  cases 


jgg  .     HEALING  OF  CONTUSED  WOUNDS. 

there  are  considerable  differences.  One  very  important  circumstance 
is,  that  in  contused  wounds  the  nutrition  of  the  edges  of  the  skin  and 
soft  parts  is  more  or  less  extensively  destroyed  or  impaired,  or,  to  ex- 
press  this  more  anatomically,  the  circulation  and  nerve  influence  in  the 
borders  of  contused  wounds  are  more  or  less  lost.  This  at  once  pre- 
vents the  possibility  of  healing  by  first  intention,  as  this  requires  per- 
fect vitality  in  the  surfaces  of  the  wound.  Hence  contused  wounds 
always  heal  with  suppuration. 

This  observation  causes  us  to  introduce  sutures  or  try  firm  union  by 
plasters  very  rarely;  you  miay  consider  this  as  a  general  rule.  There 
are  exceptions  to  this  rule,  which  you  will  only  learn  exactly  in  the 
clinic,  and  of  which  I  shall  only  incidentally  remark,  that  occasionally 
we  fasten  large,  loose  flaps  of  skin  in  their  original  position,  not  be- 
cause we  expect  them  to  unite  by  first  intention,  but  that  they  maj 
not  from  the  first  retract  too  much  and  atrophy  to  too  great  an  ex- 
tent. 

Granulation  and  suppuration  are  esentially  the  same  as  in  wounds 
with  loss  of  substance,  except  that  they  are  slower,  and  we  might  say 
more  uncertain  at  many  places.  In  incised  wounds  with  loss  of  sub- 
stance also  a  thin  superficial  layer  of  tissue  is  occasionally  lost,  if  it 
be  not  very  well  nourished ;  but  this  is  insignificant  as  compared  with 
the  extensive  loss  of  tissue-shreds  that  occurs  in  contused  wounds. 
Many  days,  often  for  weeks,  tags  of  dead  (necrosed)  skin,  fascia,  and 
tendons,  hang  to  the  edges  of  the  wounds,  while  other  parts  are 
luxuriantly  granulating.  ^ 

This  process  of  detachment  of  the  dead  from  the  living  tissue 
takes  place  as  follows :  A  cell  infiltration  and  formation  of  vessels,  lead- 
ing to  development  of  granulations,  start  from  the  borders  of  the 
new  tissue;  graniilations  form  on  the  border  of  the  healthy  tissue,  and 
their  surface  breaks  down  into  pus.  With  this  change  to  the  fluid  state 
as  it  were  the  solution  and  melting  of  the  tissue,  of  course  the  cohe- 
sion of  the  parts  must  cease,  and  the  dead  shreds,  which  previously 
were  in  continuity  with  the  living  tissue  by  their  filamentary  connec- 
tion, must  now  fall. 

Hence  part  of  the  surface  of  contused  wounds  almost  alwaj^s  be- 
comes necrosed  (from  veKpog,  dead),  gangrenous  (from  r]  ydyypacva 
from  ypaivG)^  I  consume),  which  are  both  expressions  for  parts  in 
which  circulation  and  innervation  have  ceased,  or  which  are  entirely 
dead.  The  part  Avhere  the  detachment  takes  place  is  technically 
called  the  line  of  demarcation  of  the  gangrene.  These  technical 
terms,  which  refer  to  every  variety  of  gangrene,  no  matter  how  it 
occiu-s,  you  must  only  notice  provisionally  here.  I  will  try  to  render 
this  process  of  detachment  of  necrosed  tissue  by  suppuration  more 
distinct  by  means  of  a  diagram. 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.     169 

In  the  portion  of  connective  tissue  represented,  suppose  c,  the 
border  of  the  -wound,  be  so  destroyed  by  the  injury  that  its  circulation 
is  arrested  and  it  is  no  longer  nourished  ;  the  blood  is  coagulated  in 
the  vessels  as  far  as  the  shading  extends  in  the  diagram.  Now  cell- 
infiltration  and  inflammatory  new  formation  begin  at  the  outer  edge  of 
the  li^-ing  tissue,  at  the  border  between  a  and  h  where  the  vessels  termi- 
nate in  loops ;  these  vascular  loops  dilate,  groAV,  and  multiply  ;  in  the 
tissue  the  infiltration  is  constantly  increased  by  wandering  cells,  as  if 
the  edge  of  the  wound  were  here ;  granulation  tissue  is  formed ;  this 
turns  to  pus,  on  the  surface,  that  is,  close  to  the  dead  tissue,  and 
then  of  course  the  necrosed  part  falls,  because  its  cohesion  with  the 
living  tissue  has  ceased.  Hence  detachment  of  the  necrosed  shreds  of 
tissue  results  from  inflammation  with  suppuration  ;  when  the  dead  por- 
tion of  tissue  has  fallen,  the  subjacent,  suppurating  layer  of  granula- 
tions comes  to  light,  having  been  already  developed  before  the 
detachment  of  the  necrosed  part.  What  you  here  see  in  connective 
tissue  is  true  of  the  other  tissues,  bone  not  excepted. 


Fig.  39. 


Oia^am  of  (he  process  of  detachment  of  dead  connective  tissue  in  contused  wounas.    Magcl- 
fled  300  diameters :  a,  crushed  necrosed  part ;  6,  living  tissue ;  c,  surface  of  the  vv^ound. 


170  HEALING  OF  CONTUSED  WOUNDS. 

In  many  cases,  on  the  fresh  borders  of  the  wound  we  may  see 
about  how  much  will  die,  but  by  no  means  in  all  cases,  and  we  can 
never  decide  from  the  first  as  to  the  bordering  line  of  the  dead  tissue. 

Completely  crushed  skin  usually  has  a  dark-blue  violet  appearance 
and  feels  cold;  in  other  cases  we  at  first  see  no  change  in  it,  but  in  a 
few  days  it  is  white,  without  sensation,  later  it  becomes  gray,  or,  when 
quite  dry,  grayish  or  brownish  black.  These  various  colors  depend 
chiefly  on  the  amount  of  coagulated  blood  remaining  in  the  vessels  or 
infiltrated  in  the  tissue  itself  by  the  partial  rupture  of  the  vessels. 
The  healthy  skin  is  bordered  by  a  rose-red  line  which  loses  itself  in  a 
diflFuse  redness ;  this  is  due  to  collateral  dilatation  of  the  capillaries, 
and  is  partly  also  a  symptom  of  fluxion,  of  which  we  have  before 
spoken ;  it  is  the  reaction  redness  about  the  wound,  which  we  have 
already  described ;  for  the  living  wound-surface  only  begins  where 
the  blood  still  flows  through  the  capillaries. 

In  muscles,  fuscia3,  and  tendons,  we  can  decide  far  less  frequently, 
and  often  not  at  all,  from  the  appearance  at  first,  how  far  they  will  be 
detached. 

The  time  required  for  the  dead  tissue  to  be  separated  and  detached 
from  the  living  varies  greatly  with  the  different  tissues.  This  de- 
pends first  on  the  vascularity  of  the  tissues ;  the  richer  a  tissue  in 
capillaries,  the  softer  it  is,  the  more  readily  cells  sjDread  in  it,  and  the 
richer  it  is  by  nature  in  cells  capable  of  development,  so  much  the 
more  rapidly  will  the  formation  of  granulations  and  the  detachment 
of  the  necrosed  parts  come  about.  All  these  circumstances  combine 
best  in  the  subcutaneous  cellular  tissue  and  in  the  muscles,  least  so  in 
tendons  and  fasciaa ;  the  cutis  stands  in  the  middle  in  this  respect. 
The  circumstances  are  the  most  unfavorable  for  the  bones ;  conse- 
quently the  separation  of  the  dead  from  the  living  takes  place  most 
slowly.  Of  this  more  hereafter.  Rich  supply  of  nerves  seems  to 
have  little  eS"ect  in  this  process. 

But  there  are  many  other  influences  that  hinder  the  detachment 
of  the  dead  parts,  or,  what  is  the  same  thing,  that  retard  the  forma- 
tion of  granulations  and  pus  ;  such  as  continued  action  of  cold  on  the 
wound,  as  might  be  efl"ected  by  applications  of  bladders  of  ice.  The 
cold  keeps  the  vessels  contracted.  The  cell-movements,  the  escape  of 
cells  from  the  vessels,  go  on  very  slowly  under  the  influence  of  low 
temperature.  Treatment  by  continued  warmth,  as  by  the  application 
of  cataplasms,  has  the  opposite  efifect ;  by  this  means  we  increase  the 
fluxion  to  the  capillaries  and  cause  them  to  dilate,  as  you  may  readily 
see  from  the  redness  you  induce  on  the  healthy  skin  by  application  of  a 
hot  cataplasm  ;  it  is  known  that  the  high  temperature  also  hastens 
..he  cell-activity. 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.      171 

It  is  entirely  impossible  to  tell  beforehand  the  influence  of  the 
general  state  of  the  patient  on  this  local  process.  It  is  true  we  may 
say  in  general  terms  that  it  is  energetic  in  the  strong,  stout,  and 
young,  more  moderate  and  sluggish  in  weak  persons;  but  on  this 
point  we  are  often  deceived. 

From  what  has  already  been  said  you  may  suppose  that  contused 
wounds  need  much  longer  to  heal  than  more  simple  incised  ones.  It 
will  also  be  evident  that  there  may  be  circumstances  under  which 
amputation  of  the  limb  will  be  necessary,  all  the  soft  parts  being  en- 
tirely mashed  and  torn.  There  are  cases  where  the  soft  parts  are  so 
torn  from  the  bone  that  this  alone  remains  ;  so  that  on  the  one  hand 
cicatrization  cannot  occur,  and  on  the  othex',  if  the  extremity  did  heal  in 
months  or  years,  it  would  be  perfectly  useless,  and  hence  it  would  be 
better  to  remove  it  at  once.  Still,  even  the  simple  complete  detach- 
ment of  the  skin  from  the  greater  part  of  an  extremity  may  some- 
times, though  rarely,  render  amputation  necessary,  as  in  the  case  of 
a  girl  who  lost  the  skin  from  the  wrist  to  the  ends  of  her  fingers  be- 
tween the  rollers  of  a  spinning  machine. 

Fortunately  such  cases  are  not  frequent;  in  similar  injuries  of  sin- 
gle fingers  we  mostly  leave  the  detachment  to  nature,  so  that  no  more 
is  lost  than  is  absolutely  incapable  of  living  ;  for  we  should  always 
remember  in  maiming  of  the  hand  that  every  line,  more  or  less,  is  of 
importance,  that  especially  single  fingers,  and  particularly  the  thumb, 
should  be  preserved  whenever  possible,  for  such  fingers,  if  only  slightly 
capable  of  performing  their  functions,  are  more  useful  than  the  best- 
made  artificial  hand  ;  for  the  foot  and  lower  extremity  there  are 
other  considerations,  of  which  we  shall  hereafter  speak  when  we 
come  to  complicated  fractures  of  bones. 

Would  that  this  maiming  and  slow  healing,  bad  as  they  are,  were 
the  only  cares  we  had  with  our  patients  having  contused  wounds  ! 
Unfortunately  there  is  a  whole  series  of  local  and  general  complica- 
tions which  directly  or  indirectly  endanger  life.  We  shall  first 
speak  of  the  chief  local  complications ;  for  the  more  general,  the 
"  accidental  diseases  in  wounds,"  we  reserve  a  future  chapter. 

Considerable  danger  may  arise  from  the  decomposing  tissue  on 
the  wound  infecting  the  healthy  parts.  Putrid  matters  act  as  fer- 
ments on  other  organic  combinations,  especially  on  fluids  containing 
them ;  they  induce  pi'ogressive  decomposition.  We  might  wonder  that 
such  extensive  decomposition  of  the  part  which  is  injured,  if  not  killed, 
should  not  occur  more  frequently  than  it  actually  does.  But  in  most 
cases  cell-action  occurs  so  quickly  on  the  border  of  the  living  tissue 
that  a  sort  of  living  wall  is  formed  ;  this  new  formation  does  not  read- 
ily permit  the  passage  of  putrid  matter,  and  the  granulation  surface, 


J  72  HEALING  OF  CONTUSED  WOUNDS. 

if  once  formed,  is  particularly  resistant  to  such  influences.  In  many 
places  it  is  a  popular  remedy  to  cover  ulcers  with  cow-dung  and  other 
dirty  things;  this  never  causes  extensive  putrefactions  on  granulating 
wounds.  But  if  you  apply  such  substances  to  fresh  wounds,  and  bind 
tbem  firmly  on  so  that  the  tissue  may  be  mechanically  impregnated 
with  putrid  matter,  they  will  usually  become  gangrenous  to  a  certain 
depth,  and  then  an  energetic  cell-formation  opposes  the  putrefaction. 
The  reason  why  decomposing  nmtters  act  so  injuriously  on  fresh 
wounds,  and  so  slightly  on  granulating  ones,  I  consider  to  be,  that 
they  are  chiefly  absorbed  by  the  lymphatic  vessels.  If  you  inject  a 
drachm  of  putrid  fluid  into  the  subcutaneous  cellular  tissue  of  a  dog, 
the  result  will  be  inflammation,  fever,  and  septictemia.  If  you  make 
a  large  granulating  surface  on  a  dog,  and  dress  it  daily  with  charpie 
soaked  in  putrid  fluid,  it  will  have  no  decided  effect.  Certain  dis- 
solved putrid  matters  may  pass  through  the  walls  of  the  veins  and 
capillaries  ;  but  surgical  experience  teaches  that  lymphangitis  ac- 
companies poisoned  wounds  much  oftener  than  phlebitis  does. 

The  more  the  tissue  is  saturated  with  fluid,  the  more  it  is  disposed 
to  decomposition.  Hence,  the.  cases  where  great  oederaatous  swell- 
ing occurs  after  contusions  are  the  most  dangerous  in  this  respect ; 
but  this  oedema  comes  on  very  readily  as  the  venous  circulation  is 
obstructed,  from  extensive  rupture  and  crushing  of  the  vessels,  which 
indeed  often  extend  far  beyond  the  borders  of  the  wound. 

Imagine  a  forearm  caught  under  a  stone  weighing  several  hun- 
dred-weight ;  there  will  probably  be  only  a  small  skin-wound,  but 
extensive  crushing  of  the  muscles,  tendons,  and  fascise  of  the  forearm, 
and  mashing  and  rupture  of  most  of  the  veins ;  great  oedematous 
swelling  will  speedily  result,  as  the  blood  from  the  arteries  is  driven 
with  greater  energy  into  the  capillaries,  and  cannot  escape  by  its  cuf- 
tomary  passage  through  the  veins,  and  hence,  under  the  increased 
pressure,  the  serum  escapes  through  the  capillary  walls  into  the  tissue 
in  greater  amount.  What  a  tumult  in  the  circulation  and  in  the 
whole  nutrition  !  It  must  soon  appear  where  the  blood  can  still  cir- 
culate, and  where  not.  In  the  wound,  at  first,  under  the  influence  of 
the  air,  decomposition  of  the  parts  incapable  of  living  begins ;  this 
advances  to  the  stagnating  fluids,  and,  in  unfortunate  cases,  it  con- 
stantly progresses  ;  the  whole  extremity  swells  terribly  as  far  as  the 
shoulder ;  the  skin  becomes  bright  red,  tense,  painful,  covered  with 
vesicles,  from  the  escape  of  serum  from  the  cutaneous  capillaries 
under  the  epidermis.  These  symptoms  usually  appear  with  alarming 
rapidity  the  third  day  after  the  injm-y.  As  a  result  of  this  disturb- 
ance of  circulation,  the  whole  extremity  may  become  gangrenous; 
in  other  cases,  onlv  the  fasciae,  tendons,  and  some  shreds  of  skin  die. 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.      173 

Thei'e  is  cell-in51tration  of  all  the  connective  tissue  of  the  extremity 
(of  the  subcutaneous  cellular  tissue,  the  perimysium,  neui'ilemma, 
sheaths  of  the  vessels,  periosteum,  etc.),  which  leads  to  sup2:)uration. 
Toward  the  sixth  or  eighth  day  the  whole  extremity  may  be  entirely 
saturated  with  pus  and  putrid  fluid.  Theoretically,  we  might  im- 
agine such  cases  curable  ;  that  is,  we  might  imagine  that,  by  mak- 
ing suitable  openings  in  the  sldn,  the  pus  and  dead  tissue  might  be 
evacuated.  But  this  rarely  occurs  in  practice.  If  the  case  has 
undergone  the  above  distention,  generally  only  quick  amputation 
can  save  the  patient,  and  even  this  is  not  always  successful.  We 
may  term  this  variety  of  infiltration  sanio-serous.  There  is  a  cel- 
lular-tissue inflammation,  caused  by  local  septic  infection  ;  a  se2)tic 
phlegmon,  whose  products  again  have  great  tendency  to  decomposi- 
tion, but  which  finally  leads  to  extensive  suppuration  and  necrosis 
of  tissue  if  the  patient  lives  through  the  blood-infection  which  al- 
ways accompanies  it.  The  earlier  such  processes  limit  themselves, 
the  better  the  prognosis  ;  with  the  advance  of  the  local  symptoms 
the  danger  of  death  of  the  patient  increases. 

[We  have  described  the  course  of  a  contused  wound  without 
treatment ;  fortunately,  under  our  present  method,  such  results  are 
rare.  The  progressive  putrefaction  seems  due  to  decomposition  of 
the  dead  tissue  and  fluids,  the  extravasated  blood  and  lymph.  If 
this  be  prevented  we  escape  the  local  effect  of  the  decomposition, 
and  the  inflammation  is  limited  to  elimination  of  the  mortified  tis- 
sue, and  the  general  reaction  will  be  inconsiderable.  These  the- 
oretical conclusions  prove  correct  in  practice  if  the  wound  can  be 
kept  aseptic,  that  is,  putrid  decomposition  in  it  prevented.  Although 
good  results  had  been  attained  by  the  open  treatment,  it  was  prop- 
erly Lister's  method  that  allowed  us  to  follow  accurately  the  undis- 
turbed course  of  contused  wounds.  This  showed  that  in  them,  as 
in  other  traumatisms,  the  injury  itself  did  not  induce  all  the  local 
and  general  reactions,  but  that  the  dangerous  symptoms  were  due 
to  accidental  but  frequent  complications.  The  first  of  these  is  de- 
composition of  the  primary  secretions  from  the  wound,  which  are 
particularly  abundant  in  contused  wounds  ;  the  crushed  soft  parts, 
whose  circulation  is  arrested,  furnish  excellent  material  for  develop- 
ment of  putrefaction.  We  have  already  mentioned  that  decompo- 
sition depends  on  the  presence  and  development  of  minute  germs. 
These  pass  into  the  wound  with  the  air  or  otherwise,  perhaps  at  the 
time  of  the  injury,  and,  as  circumstances  favor  their  development 
by  the  supply  of  nourishment,  the  multiplication  of  cocci  goes  on 
most  rapidly,  and  the  decomposition  thus  induced  is  favored  by  the 
warmth  and  moisture,  just  as  it  would  be  if  we  placed  dead  flesh 


174      CONTUSED  AND  LACERATED  WOUNDS  OF  TUE  SOFT  PARTS. 

in  a  hatching-box  supplied  with  plenty  of  moist  air.  Hence  it  is 
very  important,  in  treating  contused  wounds,  to  prevent  infection 
from  without,  and  to  render  innocuous  any  exciters  of  decomposi- 
tion already  present.  This  being  done,  these  wounds  act  like  others. 
It  is  true,  healing  by  first  intention  is  prevented  by  the  edges  of  the 
wound  being  often  in  an  unviable  condition,  so  that  they  must  be 
detached.  But  even  to  this  there  are  many  exceptions  ;  even  where 
the  circulation  appeared  abolished  it  may  be  reestablished,  and  the 
edges  of  the  wound  will  not  die,  merely  a  thin  layer  being  detached 
by  molecular  disintegration,  and  union  may  take  place  partly  by 
first  intention,  partly  by  granulation,  but  with  very  little  suppura- 
tion. 

In  other  cases,  if  the  extravasation  be  abundant  and  circulation 
be  arrested  in  large  portions  of  tissue,  healing  by  first  intention  is 
prevented,  but  by  aseptic  treatment  the  extravasated  blood  may  be 
reabsorbed  or  become  organized  to  connective  tissue  ;  the  necrosed 
parts  remain  free  from  smell,  are  detached  slowly  without  much 
suppuration  ;  part  of  the  tissue  on  the  border  of  the  dead  and  liv- 
ing tissue  is  taken  up  by  the  vessels,  the  remainder  of  the  surface 
produces  healthy  granulations,  which  effect  the  detachment  of  the 
necrosed  tissue.  In  this  way  even  considerable  contused  wounds 
may  heal  with  very  little  inflammatory  reaction  or  suppuration  ; 
this  may  require  a  long  time  if  the  parts  are  not  well  supplied  with 
vessels,  as  fascia,  tendons,  etc.  The  dead  tissues  assume  a  grayish- 
brown,  tanned  look,  they  dry  up  from  loss  of  water  and  are  thrown 
off  as  small  shreds  or  as  molecular  detritus  in  the  secretion  of  the 
wound.  Under  aseptic  treatment  this  secretion  is  odorless,  at  first 
bloody  serum,  later  more  purulent.] 

An  important  thing  in  the  course  of  contused  wounds  is  the  ac- 
tion of  the  arteries. 

An  artery  may  be  contused,  so  as  not  to  be  fully  divided,  and 
the  blood  continues  to  flow  through  it  although  part  of  its  wall  is 
incapable  of  living,  and  becomes  detached  on  the  sixth  to  the  ninth 
day,  or  even  later.  As  soon  as  this  occurs,  there  will  be  a  haemor- 
rhage in  proportion  to  the  size  of  the  artery.  These  late  secondary 
haemorrhages,  which  usually  come  on  suddenly,  are  exceedingly 
dangerous,  as  they  attack  the  patient  unexpectedly,  sometimes  while 
sleeping,  and  frequently  remain  unnoticed  until  much  blood  has 
escaped.  Besides  the  above  manner,  late  arterial  secondary  haemor- 
rhage may  also  result  from  suppuration  of  the  thrombus,  or  of  the 
wall  of  the  artery.  I  observed  a  case  of  this  kind  late  in  the  third 
week  after  a  severe  operation  in  the  immediate  vicinity  of  the  femo- 
ral artery,  in  which,  hou^ever,  the  artery  was  not  wounded.     The 


SECONDARY   HEMORRHAGE.  175 

bleeding  began  at  night  ;  as  the  wound  looked  perfectly  well,  and 
the  patient  had  for  some  time  slept  the  whole  night,  and  for  some 
days  had  been  promised  permission  to  get  up  the  next  day,  there 
was  no  nurse  in  his  private  room.  He  woke  in  the  middle  of  the 
night  (the  twenty-second  day  after  the  operation),  found  himself 
swimming  in  blood,  and  rung  at  once  for  the  nurse.  She  instantly 
called  the  assistant  physician  of  the  ward,  who  found  the  patient 
unconscious.  He  at  once  compressed  the  artery  in  the  wound,  and, 
while  I  was  being  called,  everything  was  done  to  restore  the  pa- 
tient. I  found  him  pulseless,  unconscious,  but  breathing,  and  the 
heart  still  beating.  While  I  made  ready  to  ligate  the  femoral  ar- 
tery, the  patient  died  ;  he  had  bled  to  death.  A  very  sad  case  !  A 
man  otherwise  healthy,  strong,  in  the  bloom  of  life,  near  recovery, 
must  end  his  life  in  this  miserable  way  !  Rarely  has  a  case  so  de- 
pressed me.  Still  there  was  no  blame  anywhere  ;  as  it  happened, 
all  the  circumstances  had  been  very  favorable.  The  nurse  was 
awake  in  the  next  room,  the  physician  was  only  down  one  flight  of 
stairs  in  the  same  house,  and  was  with  the  patient  in  three  or  four 
minutes  ;  but  the  bleeding  must  have  existed  before  he  woke.  He 
was  probably  awakened  by  the  feeling  of  wetness  in  the  bed.  On 
autopsy,  a  small  spot  of  the  femoral  artery  was  found  suppurated 
and  perforated.  Fortunately,  it  is  not  always  a  femoral  that  bleeds, 
nor  does  the  bleeding  always  come  so  precipitately,  or  at  night  ; 
hence,  we  should  not  become  dissatisfied  with  our  art  from  such  a 
rare  case.  Usually  such  arterial  haemorrhages  from  suppurating 
wounds  are  at  first  insignificant,  and  soon  cease  under  styptics  or 
compression  ;  but  after  a  few  days  the  bleeding  comes  on  more 
actively,  and  is  more  difiicult  to  arrest  ;  finally,  the  haemorrhages 
recur  more  and  more  quickly,  and  the  patient  constantly  becomes 
worse.  In  all  severe  arterial  haemorrhage  instantaneous  compres- 
sion is  the  first  remedy. 

[In  contused  wounds,  secondary  hremorrhages  would  be  actually 
the  rule  if  the  arteries  and  veins  were  not  closed  early  by  thrombi. 
This  thrombosis  is  partly  due  to  the  contusion,  partly  to  the  walls 
of  the  vessel  not  being  in  condition  to  preserve  the  blood  fluid,  but 
still  not  being  so  much  injured  as  to  die  ;  the  compression  of  the 
vessels  by  the  surrounding  tissue  may  also  favor  the  extension  of 
the  thrombosis,  which  often  goes  beyond  the  portion  of  vessel  actu- 
ally crushed.] 

In  all  arterial  secondary  haemorrhages  the  first  remedy  to  be 
used  is  compression  on  the  wound,  or,  if  this  is  covered  with  a 
dressing,  on  the  main  artery  of  the  limb  ;  every  nurse  should  know 
how  to  do  this  until  an  elastic  bandage  can  be  applied  ;  and  after 


176      CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS. 

this  the  surgeon  should  be  sent  for.     Of  course  the  nurse  should 
not  leave  the  patient  for  this  purpose. 

Compression  is  only  a  palliative  remedy.  The  bleeding  may 
cease  after  it  ;  but,  if  it  be  considerable,  and  you  are  sure  of  its 
orio-in,  I  strongly  advise  you  at  once  to  ligate  the  artery  at  the 
point  of  election,  for  this  is  the  only  certain  remedy.  You  should 
do  this  the  sooner  if  the  patient  be  already  exhausted  ;  remember 
that  a  second  or  third  such  bleeding  will  surely  cause  death.  Hence, 
in  the  operative  course,  you  should  particularly  practise  ligating  the 
arteries,  so  that  you  may  find  them  so  certainly  that  you  could 
operate  when  half  asleep.  In  these  particular  cases  much  time  is 
unnecessarily  lost  in  applying  styptics,  which  usually  act  only  palli- 
atively,  or  not  at  all.  Ligation  of  arteries  is  only  a  trifle  for  one 
who  knows  anatomy  thoroughly,  and  has  employed  his  time  well 
in  the  operative  courses.  Anatomy,  gentlemen  !  Anatomy,  and 
again  anatomy  !  A  human  life  often  hangs  on  the  certainty  of  youi- 
knowledge  in  this  branch. 

While  treating  of  secondary  haemorrhages,  we  shall  speak  of 
parenchymatous  haemorrhages.  The  blood  rises  from  the  granula- 
tions as  from  a  sponge  ;  we  nowhere  see  a  bleeding,  spirting  vessel. 
The  whole  surface  bleeds,  especially  at  every  change  of  the  dressing. 
This  may  be  due  to  various  causes  :  great  friability  or  destructibil- 
ity  of  the  granulations,  that  is,  their  defective  organization,  may  be 
the  fault,  and  this  maloi'ganization  of  the  granulations  again  may 
depend  on  constitutional  diseases  (haeraorrhagic  diathesis,  scorbutis, 
septic  or  pysemic  infection^.  Still,  local  causes  about  the  wound 
are  imaginable,  as,  if  extensive  coagulation  gradually  formed  in  the 
surrounding  veins,  the  circulation  in  the  vessels  of  the  granulations 
would  be  so  affected  ;  the  pressure  of  blood  would  so  increase  that 
not  only  the  serum  might  escape  from  them,  but  they  would  rup- 
ture. It  is  true  I  have  hitherto  had  no  opportunity  of  confirming 
this  by  autopsy,  but  I  have  seen  very  few  of  these  parenchymatous 
haemorrhages.  The  latter  explanation  sounds  very  plausible  ;  so  far 
as  I  know,  it  originates  with  Stromeyer.  He  calls  such  haemor- 
rhages "haemostatic."  According  to  the  causes,  it  may  be  more  or 
less  difficult  to  arrest  suchi  haemorrhages  ;  in  most  cases  ice,  com- 
pression, and  styptics,  will  be  proper,  or,  in  severe  cases,  ligation  of 
the  arterial  trunk,  although  this  occasionally  fails.  This  form  of 
haemorrhage  occurs  chiefly  in  very  debilitated  persons,  who  have 
been  exhausted  by  suppuration  and  fever,  and  hence  has  a  bad  sig- 
nificance for  the  general  state  of  the  patient. 


INFLAMMATIOX  OF   CONTUSED   WOUNDS.  177 


LECTURE    XIII. 

Pro^'ressive  Suppuration  starting  from  Contused  Wounds.— Secondary  Inflammations  of 
the  Wound :  tlieir  Causes  ;  Local  Infection.— Febrile  Eeaction  in  Contused  Wounds  ; 
Secondary  Fever ;  Suppurative  Fever ;  Chill ;  their  Causes.— Treatment  of  Con- 
tused Wounds:  Immersion,  Ice-bladdei-s,  Irrigation  ;  Criticism  of  these  Methods.— 
Incisions.  —  Counter-openings.  —  Drainage.  —  Cataplasms.  —  Open  Treatment  of 
Wounds.— Ztsi'er's  Dressing. — Prophylaxis  against  Secondaiy  Inflammations. — In- 
ternal Treatment  of  those  severely  Wounded.  —  Quinine.  —  Opium.  —  Lacerated 
Wounds ;  Subcutaneous  Eupturo  of  Muscles  and  Tendons ;  Tearing  out  of  Muscles 
and  Tendons  ;  Tearing  out  of  Pieces  of  a  Limb. 

[We  have  already  stated  that  by  proper  antiseptic  treatment  it 
is  possible,  even  in  severe  contused  wounds,  to  reduce  inflammation 
and  suppuration  to  a  minimum  by  preventing  decomposition  of  the 
secretion  of  the  wound  and  of  the  crushed  tissues.  For  this  to  be 
possible  the  case  must  come  under  treatment  early,  but  if  no  ra- 
tional treatment  has  been  used  severe  local  and  general  disturbances 
may  occur,  even  if  the  injury  seems  insignificant  ;  in  fact,  it  is  these 
milder  cases,  where  the  fingers,  hand,  etc.,  have  been  injured  in  such 
a  way  as  not  to  prevent  their  use,  that  may  develop  the  severest 
symptoms,  because  the  patient  uses  the  part  till  he  has  to  give  it 
rest. 

Let  us  first  consider  these  dangerous  symptoms  which,  fortu- 
nately, are  growing  rarer  from  year  to  year,  as  antiseptic  treatment 
is  becoming  more  popular.  What  is  the  cause  of  the  severe  local 
and  general  symptoms  in  the  course  of  contused  wounds  ?] 

The  granulating  surface  that  develops  on  a  contused  wound  is 
generally  very  irregular,  and  often  has  numerous  angles  and  pockets; 
there  is  suppuration  not  only  of  the.  surface  of  the  wound,  but  of  the 
surrounding  contused  parts  under  the  uninjured  skin  ;  hence  the 
neighboring  skin  often  appears  undermined  by  pus.  The  inflamma- 
tion and  suppuration  often  unexpectedly  extend  between  the  muscles, 
along  the  bones,  and  in  the  sheaths  of  the  tendons,  because  these 
parts  were  also  affected  by  the  injury.  The  process  of  inflammation, 
once  excited,  creeps  along,  especially  in  the  sheaths  of  the  tendons 
and  in  the  cellular  tissue  ;  new  collections  of  pus  form,  superficially 
or  in  the  depths  ;  the  injured  jDart  remains  swollen  and  oedematous  ; 
on  the  surface  the  granulations  are  smeary,  yellow,  swollen,  and 
spongy.  When  we  press  in  the  vicinity  of  the  wound,  the  pus  flows 
13 


178  INFLAMMATION  OF  CONTUSED  WOUNDS. 

slowly  from  smaller  or  larger  openings,  whicli  have  formed  sponta- 
neously, and  this  pus  which  has  remained  for  a  time  in  the  depth  is 
not  infrequently  thin  and  bad  smelling.  Should  the  process  con- 
tinue long,  the  patient  becomes  more  miserable  and  weak ;  he  has 
high  and  continued  fever.  A  wound,  which  perhaps  at  first  appeared 
insignificant,  perhaps  about  the  hand,  has  extended  horribly,  and  in- 
duced severe  general  disturbance.  The  sheaths  of  the  tendons  about 
the  hands  and  feet  are  particularly  favorable  for  the  extension  of  deep 
suppurations,  which  readily  attack  the  joints,  while,  on  the  other 
hand,  articular  inflammations  of  the  extremities  readily  attack  the 
sheaths  of  the  tendons.  These  states  may  take  a  very  dangerous  turn, 
and  you  should  be  constantly  on  your  guard.  From  the  constant  pu- 
rulent infection,  as  well  as  from  the  daily  loss  of  pus,  even  the  strong- 
est man  may  emaciate  in  a  few  weeks,  and  die  with  symptoms  of 
febrile  marasmus. 

We  now  know  two  forms  of  inflammation  which  may  attack  con- 
tused wounds :  1.  Rapid,  progressive,  septic  inflammation,  which 
begins  about  the  wound  during  the  first  three  or  four  days  (rarely  in 
less  than  twenty-four  hours,  and  just  as  rarely  after  the  fourth  day), 
and  which  is  caused  by  local  infection  from  parts  that  decompose  in 
the  wound.  2.  Progressive  purulent  inflammation,  which  is  particu- 
larly apt  to  occur  in  wounds  of  the  hands  or  feet  during  the  cleansing 
of  the  wound  from  necrosed  shreds  of  tissue,  without  the  pus  becom- 
ing ichorous,  although  butyric  acid  often  formed  in  it. 

But,  even  when  the  wound  has  entirely  cleaned  ofiF  and  granu- 
lated, when  the  inflammation  is  bounded,  and  the  wound  begins  to 
cicatrize,  new  inflammation,  with  severe  results,  may  begin.  These 
secondary  progressive  inflammations  of  suppurating  wounds,  occur- 
ring even  several  weeks  after  the  injury,  and  sometimes  coming  as 
unexpectedly  as  lightning  from  a  clear  sky,  are  of  great  importance, 
and  are  sometimes  very  dangerous.  They  are  almost  always  of  sup- 
purative nature,  and  may  be  fatal  from  intense,  phlogistic,  constitu- 
tional infection,  just  as  often  as  the  primary  progressive  suppurations. 
In  some  cases,  also,  they  prove  dangerous  from  their  location,  as  in 
wounds  of  the  head.  These  cases  are  so  strikinar  and  trasfical  that 
we  must  give  them  special  consideration.  Suppose  you  have  brought 
a  case  of  severe  crushing  of  the  leg,  with  fracture,  successfully 
through  the  first  dangers.  The  patient  has  no  fever;  the  wound 
granulates  beautifully,  and  has  even  begun  to  cicatrize.  Suddenly,  in 
the  fourth  week,  the  wound  begins  to  swell ;  the  granulations  are 
croupous  or  spongy,  the  pus  thin ;  the  whole  hmb  swells.  The  pa- 
tient again  has  high  fever,  perhaps  repeated  chills.  The  symptoms 
may  pass  off,  and  every  thing  go  on  in  the  old  track ;  but  it  often 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.     179 

turns  out  badly.  In  a  few  days  tlie  strongest  man  may  become  a 
corpse.  Some  time  since  such  a  case  occurred  in  Ztirich,  in  a  fellow- 
student  with  a  wound  of  the  head ;  it  may  serve  you  as  a  warning 
example.  The  young  man  received  a  blow  over  the  left  vertex ;  the 
bone  was  injured  very  superficially ;  the  wound  healed  quickly  by 
first  intention ;  only  a  small  spot  continued  to  suppurate.  As  the 
patient  felt  quite  well,  he  paid  no  attention  to  the  little  wound,  and 
went  about  as  if  perfectly  well.  Suddenly,  in  the  fom-th  week,  after 
a  walk,  he  had  severe  headache  and  fever.  The  following  day  there 
was  about  a  teaspoonful  of  pus  collected  under  the  cicatrix,  which 
was  evacuated  by  an  incision.  This  did  not  have  the  desired  beneficial 
effect  on  the  general  condition  ;  the  fever  remained  the  same.  In  the 
evening  delirium  began,  then  sopor.  Tlie  fourth  day  the  previously 
vigorous  man  was  dead.  It  was  easy  to  diagnose  that  there  had  been 
suppurative  meningitis.  This  was  proved  on  autopsy.  Although  at  the 
S})0t,  as  big  as  a  pea,  where  slight  suppuration  had  been  so  long 
kept  up,  the  bone  was  but  slightly  discolored  by  purulent  infiltration, 
still  the  suppuration  on,  in,  and  under  the  dura  mater  was  greatest  at 
the  part  exactly  corresponding  to  this  point ;  so  that  the  new  inflam- 
mation undoubtedly  started  fi'om  the  wound.  A  short  time  since, 
here  in  Vienna,  in  private  practice,  I  saw  a  perfectly  similar  case,  alsa 
fatal,  in  a  man  who  several  weeks  previously  had  received  an  appar- 
ently insignificant  wound,  from  a  piece  of  a  soda-water  bottle  that 
burst,  at  the  upper  part  of  the  forehead,  along  the  margin  of  the 
hairy  scalp. 

The  inflammations  occurring  under  such  circumstances,  as  already 
remarked,  are  usually  of  a  diffusely  purulent  character,  but  other 
forms  accompany  it,  or  occur  spontaneously,  such  as  diphtheritic  in- 
flammation of  the  granulations  [traumatic  diphtheria.,  hospital  gan- 
grene)., inflammation  of  the  lymphatic  trunks  {lymphangitis),  and  a 
specific  form  of  capillary  lymphangitis  of  the  skin,  erysipelas  or  ery- 
sipelatous inflammation  ;  and,  lastly,  inflammation  of  the  veins  [phle- 
bitis). Not  infrequently  all  of  these  processes  may  be  seen  mixed 
together.  We  shall  hereafter  study  these  diseases  more  accurately, 
under  accidental  traumatic  diseases.  But  here  we  must  consider  the 
causes  of  these  secondary  inflammations,  before  passing  to  the  treat- 
ment of  contused  wounds ;  and,  in  so  doing,  we  must  anticipate 
somewhat.  All  of  these  forms  of  inflammation,  and  their  reflex 
action  on  the  organism,  are  so  intertwined,  that  it  is  impossible  to 
speak  of  one  without  mentioning  the  other. 

As  causes  of  secondary  inflammations  in  and  around  suppurating 
wounds  that  have  begun  to  heal,  we  may  mention  the  following :  1. 
Excessive  flow  of  blood  to  the  wound,  such  as  may  be  induced  bv  too 


180  INFLAMMATIOX   OF  CONTUSED   WOUNDS. 

much  motion  of  tlie  part,  or  bj  great  bodily  exertion,  as  well  as  by 
exciting  drinks,  mental  agitation,  in  short,  by  any  great  excitement ; 
in  wounds  of  the  head,  such  congestions  are  particularly  dangerous. 
Congestion,  as  caused  by  too  tight  bandages,  may  prove  injurious  in  the 
same  way.  2.  Local  or  general  catching  cold ;  about  catching  cold  as 
a  cause  of  inflammation  we  know  little  more  than  the  simple  fact  thai, 
under  certain  circumstances,  which  cannot  bo  accurately  defined,  a 
sudden  change  of  temperature  induces  inflammations,  especially  in  a 
locus  minoris  resistentice  of  an  individual;  in  a  wounded  person  the 
wound  is  always  to  be  considered  as  a  locus  minoris  resistentice.  The 
danger  of  catching  cold  after  injury  was  certainly  over-estimated 
formerly ;  I  hardly  know  of  any  certain  examples.  3.  3Iechcmical 
irritation  of  the  wound.  This  is  very  important.  The  pus  from  the 
wound  is  never  reabsorbed  by  the  uninjured  granulations  ;  but,  if  they 
be  destroyed  by  mechanical  manipulations,  as  by  improper  dressings, 
much  probing,  etc.,  which  cause  the  wound  to  bleed  frequently,  new 
inflammations  may  be  induced.  Any  foreign  bodies  in  the  wound 
might  prove  serious  in  this  way,  such  as  pieces  of  glass,  lead,  or  iron, 
or  sharp  splinters  of  bone ;  for  the  first  changes  which  take  place  in 
the  wound,  the  vicinity  of  such  foreign  bodies  is  less  important,  but, 
when,  from  muscular  movements,  and  the  motion  communicated  to  tiie 
tissue  from  the  arteries,  the  sharp  angles  of  a  foreign  body  keep  up 
constant  friction  in  a  part,  severe  inflammation  occurs  after  a  time. 
4.  Chetnical  ferments  j  here  I  mention  first  soft  foreign  bodies,  such 
as  pieces  of  clothing,  paper  wads,  which  have  entered  the  tissue 
through  gunshot  wounds  ;  these  substances  become  impregnated  with 
the  secretions  from  the  wound,  then  the  organic  material  (paper,  wool) 
decomposes,  and  acts  as  a  caustic  and  ferment  in  the  wound.  I  am  in- 
clined to  believe  that  necrosed  splinters  of  bone  also  act  rather  as  chem- 
ical than  as  mechanical  irritants  ;  in  the  Haversian  canals,  or  medullary 
cavity,  they  always  contain  some  organic  decomposing  substance ;  all 
such  pieces  of  bone  have  a  putrid  smell  when  extracted ;  if  the  sur- 
rounding granulations  were  partly  destroyed  by  the  sharp  angles  of 
such  a  fragment  of  bone,  the  putrid  matter  passes  from  it  into  the 
open  lymphatic  vessels,  or  possibly  even  into  the  blood-vessels,  and 
so  induces,  not  only  local,  but,  at  the  same  time,  constitutional  infec- 
tion. Necrosed  tags  of  tendon  and  fascia  at  the  bottom  of  suppu- 
rating wounds  may  induce  the  same  results,  although  this  rarely  hap- 
pens. In  hospitals,  especially,  there  are  some  rare  cases  where  we  can 
find  none  of  the  above  causes ;  such  occurrences  naturally  induce  pe- 
culiar alarm,  and  attempts  have  been  made  to  explain  them  by  certain 
injurious  influences  of  the  hospital  atmosphere,  especially  such  as  is 
filled  with  the  smell  of  pus.     Many  circumstances  speak  against  the 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.     181 

new  that  the  injurious  substances  are  gaseous ;  by  good  ventilation 
the  air  of  the  hospital  may  be  kept  pure,  but  this  is  no  protection 
against  the  affection  in  question  ;  moreover,  we  cannot  excite  inflam- 
mations by  any  of  tne  gases  developing  from  pus  or  putrefying  sub- 
stances, unless,  perhaps,  by  sulphuretted  hydrogen,  when  dissolved  in 
water  and  injected  into  the  subcutaneous  cellular  tissue.  Putrid  fluids 
and  pus  from  other  patients  would  not  intentionally  be  brought  in 
contact  with  woiMids ;  we  have  previously  shown  that  the  vicinity  of 
the  wound  may,  under  some  circumstances,  be  infected  by  pus  from 
the  wound,  and  excited  to  new  inflammation.  Hence  there  is  little 
left  but  the  supposition  that  the  injuriously-acting  substances  are  of  a 
molecular,  dust-like  nature ;  they  may  float  about  in  the  air  of  the 
hospital,  but  they  ma}-  also  adhere  to  the  bandages,  charpie,  com- 
presses, etc.,  with  which  we  dress  the  M'ounds,  or  to  the  instruments, 
forceps,  probes,  sponges,  etc.,  with  which  we  touch  the  \A'Ound.  May 
the}'  not  be  fungi,  or  other  organic  germs,  whose  nature  we  do  not  at 
present  know,  like  those  we  know  to  excite  fermentation  ?  This  is 
possible,  for  in  every  cubic  foot  the  air  holds  quantities  of  such  germs, 
and  in  the  hospital  such  organic  germs  of  animal  or  vegetable  nature 
might  develop  in  the  secretions  from  wounds,  in  the  sputum  or 
excrement,  and  the  more  so  in  proportion  as  the  readily-decomposing 
secretions  and  excretions  are  collected  in  hosj^itals,  or  in  badly- 
built  water-closets  and  sewers.  On  this  point  we  can  only  haz- 
ard conjectures,  while  we  may  make  experiments  with  dry  putrid  sub- 
stances and  dry  pus,  by  powdering  them,  and  then  introducing  them 
Into  the  healthy  tissue  of  animals.  Such  experiments  have  been  made 
by  0.  Weber  and  myself,  and  they  have  shown  that  both  animal  and 
v'egetable  putrid,  dry  substances,  as  well  as  dry  pus,  induce  inflam- 
mation ;  if  Ave  pulverize  these  substances,  stir  them  up  quickly  with 
water,  then  inject  them  into  the  subcutaneous  cellular  tissue  of  ani- 
mals, they  will  excite  progressive  inflammation,  just  as  putrid  fluids 
and  fresh  pus  do.  Now,  it  must  at  once  be  acknowledged  that  in  a 
hospital  such  injurious  dust-like  bodies  niay  readily  cling  to  dressings 
and  bedclothes  ;  iDOSsibly,  also,  to  instruments.  In  short,  it  is  possible 
that  the  direct  injurious  influence  of  hospital  air  on  a  wound  may  be 
due  to  fine  dust-like  particles  of  putrid  or  purulent  matter  coming  in 
contact  with  it  from  the  dressings  or  instruments.  There  can  be  no 
doubt  that  such  injurious  materials  may  enter  the  body  in  other  ways 
besides  through  wounds,  as  through  the  lungs  ;  indeed,  we  explain  the 
occurrence  of  all  so-called  infectious  diseases  by  the  entrance  in  the  or- 
ganism of  substances  which  have  a  sort  of  fermenting  influence  on  the 
blood ;  but,  whether  the  morbid  materials  which  excite  the  infectious 
diseases  chiefly  occurring  in  the  wounded  be  different  from  those  arising 


182  INFLAMMATION  OF  CONTUSED  WOUNDS. 

from  the  wound  itself,  may  be  a  disputed  point,  so  far  as  we  at  present 
know.  We  shall  return  to  this  point  when  speaking  of  accidental 
traumatic  diseases.  You  will  suspect  me  of  contradicting  myself  here, 
because  in  yesterday's  lecture  I  said  that  no  molecular  body  could  en- 
ter the  tissues  through  an  uninjured  granulation-surface.  I  must  still 
claim  this  as  usual ;  a  strong,  uninjured  granulation-surface  is  a  de- 
cided protection  against  infection  through  the  wound.  But,  when  the 
infecting  material  itself  is  very  irritating,  so  that  it  destroys  the 
granulating  surface  by  causing  decomposition,  a  passage-way  is  opened 
for  the  poison  to  enter  the  tissues.  Still  more,  there  are  certain  sub- 
stances which  are  carried  into  the  granulation-tissue,  and  perhaps 
even  further,  by  the  pus-cells.  If  you  sprinkle  a  granulating  surface 
on  a  dog  with  finely-powdered  carmine,  some  cells  take  up  the  small 
carmine  granules  and  w  ander  with  it  into  the  granulation-substance ; 
after  a  tune  you  find  cells  with  carmine  in  the  granulation-tissue.  I 
consider  this  an  abnormal  retrograde  movement  of  the  pus-cells,  which 
we  generally  believe  to  pass  from  the  granulation-tissue  to  the  surface 
of  the  womid;  it  is  true,  no  one  has  seen  this.  Nevertheless,  from  the 
above  experiment,  it  is  evident  that  even  molecular  substances  may 
pass  from  without  into  the  tissue  of  the  edges  of  the  wound,  and,  if 
these  substances  be  very  decomposable  or  cauterant,  they  will  excite 
active  inflammation.  But  all  of  the  millions  of  molecular  organisms 
in  the  atmosphere  are  not  taken  up  by  the  wound,  nor  do  they  each 
induce  inflammation.  My  belief  is  that  all  micrococci  do  not  neces- 
sarily have  a  phlogogenous  action,  but  only  those  which  are  formed 
in  certain  products  of  inflammation,  such  as  decomposing  pus  or 
fluids  of  the  body,  putrid  urine,  etc.,  and  which  have  there  ab- 
sorbed the  ferment.  This  is  the  most  frequent  cause  of  micrococ- 
cus in  hospital ;  hence  its  development  there  is  to  be  combated  with 
particular  energy.  I  do  not  believe  that  these  substances,  whether 
lifeless  or  living  molecules,  are  always  the  same,  but  I  think  they 
are  very  numerous,  as  are  the  causes  of  inflammation  generally  ; 
they  may  all  have  certain  chemical  peculiaiities  in  common,  as  we 
might  suppose  from  their  similar  action,  although  we  know  nothing 
about  them,  except  this  action;  they  also  difl'er  somewhat  in  their 
mode  of  action  on  this  or  that  tissue ;  the  absorbability  of  such  sub- 
stances may  vary  with  the  part  of  the  body,  and  possibly,  also,  with 
the  individual;  but  the  large  number  of  these  injurious  substances 
is,  in  fact,  small  as  compared  with  the  innumerable  variety  of  organic 
substances  generally. 

Febrile  reaction  is  usually  greater  from  contused  than  from  incised 
wounds;  according  to  our  view,  this  is  because,  from  the  decomposi- 
tion, which  is  much  more  extensive  in  crushed  than  in  incised  parts, 


CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS.     183 

far  more  putrid  matter  enters  tlie  blood.  IS  in  any  case  the  putrid 
matter  is  particularly  intense,  or  very  much  of  it  is  taken  up  (es- 
pecially in  diffuse  septic  inflammations),  the  fever  assumes  the  charac- 
ter of  so-called  putrid  fever  /  the  state  thus  induced  is  called  septi- 
cemia ;  we  shall  hereafter  study  it  more  closely.  If  the  suppurative 
inflammation  extends  from  the  w^ound,  there  is  a  corresponding  con- 
tinued inflammatory  or  suppurative  fever ;  this  has  the  character  of 
remittent  fever  with  very  steep  curves  and  occasional  exacerbations, 
mostly  due  to  progress  of  the  inflammation,  or  to  circumstances  that 
favor  the  reabsorption  of  pus.  If  we  call  the  fever,  that  often,  but 
not  always,  accompanies  traumatic  inflammation,  simple  traumatic 
fever ^  we  may  term  the  fever  that  occurs  later  '"'■  secondary  fever  J''  or 
"  suppurative  f every  This  may  immediately  succeed  the  traumatic 
fever,  if  the  traumatic  inflammation  progresses  regularly  ;  but  the 
traumatic  fever  may  have  ceased  entirely,  and  the  wound  be  already 
healing,  and  when  new  secondary  inflammations,  of  which  we  have 
fully  treated,  attack  the  wound,  they  are  accompanied  by  new  suppu- 
rative fever ;  in  short,  inflammation  and  fever  go  parallel.  Occasion- 
ally, indeed,  the  fever  appears  to  precede  the  secondary  inflammation, 
but  this  is  probably  because  the  first  changes  in  the  wound,  which 
may  be  only  slight,  have  escaped  our  observation.  At  all  events,  on 
every  accession  of  fever  that  we  detect,  we  should  at  once  seek  for  the 
new  point  of  inflammation,  which  may  be  the  cause.  I  am  far  from 
asserting  that  it  is  necessary  to  measure  the  temperature  in  all  cases 
of  wounds ;  undoubtedly  any  experienced  surgeon,  accustomed  to 
examine  patients,  would  know  the  condition  of  his  patient  without 
measuring  the  temperature,  just  as  an  experienced  practitioner  may 
diagnose  pneumonia  without  auscultation  and  percussion  ;  but  no  one 
who  understands  the  significance  of  bodily  temperature  doubts  that 
its  measurement  may  sometimes  be  a  very  important  aid  to  diagnosis 
and  prognosis.  It  is  with  it  as  with  every  other  aid  to  observation  ; 
it  is  not  difficult  to  detect  a  dull  percussion-sound  in  the  thorax  where 
it  should  not  exist ;  but  the  art  and  science  of  determining  the  sig- 
nificance of  this  dull  percussion-sound  in  any  given  case  must  be 
learned  ;  so,  too,  with  measurement  of  temperature  :  for  instance,  we 
must  learn  whether  a  low  temperature  in  any  given  case  be  of  good 
or  bad  omen.  I  shall  enter  into  more  detail  on  this  subject  in  the 
clinic. 

Experience  teaches  that  secondary  fever  is  often  more  intense 
than  primary  traumatic  fever.  While  it  is  most  rare  for  the  latter  to 
begin  with  a  chill  (a  slight  chilliness  after  great  loss  of  blood  and 
severe  concussion  is  not  usually  accompanied  by  high  temperature), 
it  is  not  at  all  so  for  a  secondary  fever  to  commence  with  severe  "  chill.'* 


184  INFLAMMATION  OF  CONTUSED  WOUNDS. 

We  shall  at  once  study  this  peculiar  plaenoraenon  more  attentively 
Formerly  the  chill  was  always  regarded  as  essentially  dependent  on 
blood-poisoning ;  if  we  now  regard  fever  generally  as  due  to  intoxi- 
cation, we  must  seek  some  special  cause  for  the  chill.  Observation 
shows'that  the  chill,  which  is  always  followed  by  fever  and  sweating, 
is  always  accompanied  by  rapid  -elevation  of  temperature.  If  we  ther- 
mometrically  examine  the  temperature  of  the  blood  of  a  patient  with 
chill,  we  find  it  high  and  rapidly  increasing,  while  the  skin  feels  cool ; 
the  blood  is  driven  from  the  cutaneous  vessels  to  the  internal  organs. 
As  already  remarked,  Traube  considers  this  as  the  cause  of  the  ab- 
normal febrile  elevation  of  temperature.  We  shall  not  discuss  this  at 
present ;  at  all  events,  there  is  so  great  a  difference  between  the  air 
and  the  bodily  temperature  that  the  patient  feels  chilled.  If  we  un- 
cover a  patient  with  fever,  who  lies  wrapped  up  in  bed  and  does  not 
feel  chilly,  he  at  once  begins  to  shiver.  Man  has  a  sort  of  conscious 
feeling  for  the  state  of  equilibrium  in  which  his  bodily  temperature 
stands  to  the  surrounding  air ;  if  the  latter  be  rapidly  warmed,  he  at 
once  feels  warmer,  if  it  be  rapidly  cooled,  he  at  once  feels  cool,  chilly. 
This  trivial  fact  leads  us  to  another  observation.  This  sensitiveness 
for  warmth  and  cold,  this  conscious  feeling  of  change  of  temperature, 
varies  with  the  individual ;  it  may  also  be  increased  or  blunted  by  the 
mode  of  life ;  some  persons  are  always  warm,  others  ever  too  cold, 
while  for  others  the  temperature  of  the  air  is  comi:>aratively  a  matter 
of  indifference.  The  nervous  system  has  much  to  do  with  this.  Ac- 
ciu-ate  studies  of  Traube  and  Jochtnann  have  in  fact  shown  that  the 
nervous  excitability  of  an  individual  has  a  great  effect  as  to  whether, 
in  a  rapid  elevation  of  temperature  of  the  blood,  the  change  will  be  much 
perceived  or  not ;  hence  that  in  torpid  persons,  in  comatose  condi- 
tions, chills  do  not  so  readily  occur  with  fever,  as  they  do  in  irritable 
persons  already  debilitated  by  long  illness.  I  can  only  confirm  this 
from  my  own  observation.  Although  I  have  a  general  idea  that, 
where  there  is  sufficient  irritability,  rapid  elevation  of  temperature 
and  chill  chiefly  occur  when  a  quantity  of  pyrogenous  material  enters 
the  blood  at  once,  still  I  cannot  deny  that  the  quality  of  the  material 
is  also  important.  We  know  nothing  of  this  quality  chemically,  but 
we  may  conclude  that  it  has  varieties,  because  both  the  fever-symp- 
toms and  their  duration  often  vary  greatly,  and  that  this  does  not 
solely  depend  on  the  peculiarities  of  the  patient.  According  to  my 
observations,  in  man  reabsorption  of  pus  and  recent  products  of  in- 
flammation is  more  apt  to  induce  chills  than  is  absorption  of  putrid 
matter,  which  is  perhaps  more  poisonous  and  dangerous.  I  do  not 
wish  to  Aveary  you  with  too  many  of  these  considerations,  and  so 
shall  return  to  the  subject  in  the  section  on  general  accidental  trau- 


TREATMENT  OF  CONTUSED  WOUNDS.  185 

matic  and  inflammatory  diseases,  which  you  may  regard  as  a  con- 
tinuation of  this  study  of  fever.  I  will  only  remark  here  that  both 
the  septic  and  purulent  primary  and  secondary  inflammations,  with 
their  accompanying  fever,  may  also  occur  from  incised  wounds, 
especially  after  extensive  operations  (as  amputations  and  resections). 
We  have  considered  this  condition  along  with  contused  wounds, 
because  it  complicates  them  much  more  frequently  than  it  does 
ordinary  incised  wounds. 

[Decomposition  may  begin  in  a  contused  Avound  within  twenty- 
four  hours  after  the  injury  ;  the  tissue  may  have  been  crushed  so 
that  circulation  is  arrested  and  its  substance  infiltrated  with  blood 
and  lymph  ;  it  may  also  contain  foreign  bodies,  and  ferments  from 
the  air  enter  it  ;  hot  weather  may  favor  the  decomposition,  and  even 
in  a  few  hours  the  primary  secretion  may  have  an  odor.  If  some 
of  this  secretion  be  injected  into  an  animal  it  induces  intense  symp- 
toms of  local  and  general  septic  infection. 

Progressive  suppurative  inflammation  of  cellular  tissue,  occur- 
ring especially  in  wounds  of  the  hands  and  feet,  may  develop  with- 
out the  pus  becoming  foul ;  this  is  due  to  extension  to  the  healthy 
tissue,  the  pus  acting  as  an  infector  ;  whei'ever  it  enters  the  tissue 
it  induces  inflammation  and  suppuration,  which  may  thus  creep 
along  the  interspaces  of  the  connective  tissue  between  the  ten- 
dons, etc. 

In  granulating,  secondarily  inflamed  wounds  the  whole  granula- 
tion layer,  the  interspaces  in  the  connective  tissue  under  it,  many 
blood  and  lymph  vessels,  may  be  found  filled  with  micrococci,  ap- 
parently in  rapid  growth,  and  fungi  active  or  quiescent  may  be 
fouhd  in  the  fluid  secretion,  even  while  it  has  no  putrid  odor  ;  in 
fact,  this  is  only  apt  to  occur  when  the  pus  is  confined  in  pockets. 

When  permanent  germs  have  developed  from  these  micrococci 
they  prove  quite  resistant,  and  may  be  dried  and  kept  for  some 
time  ;  then  under  favorable  conditions,  as  in  decomposing  organic 
matter,  they  develop  and  multiply  enormously  and  penetrate  the 
tissue,  inducing  inflammation  mechanically  by  their  numbers  and 
chemically  by  transporting  phlogogenous  material.  To  live  and 
multiply,  the  fungi  must  supplant  the  albuminous  bodies  ;  this 
double  action  enables  them  to  penetrate  healthy  granulations  ; 
dust-like  micrococci,  or  irritant  matter  containing  spores,  reaching 
the  granulating  surface,  may  attack  the  life  of  the  cells  and  destroy 
the  surface. 

Infecting  matters  may  enter  the  economy  by  the  air-passages  ; 
infectious  diseases  spread  from  substances  entering  the  organism. 


186      CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS. 

which  act  as  poisons  on  the  blood  and  the  whole  body  ;  but  we  can- 
not say  if  the  same  morbid  matters  inducing  the  infectious  diseases 
occurring  especially  in  the  wounded,  may  enter  anywhere  except  by 
the  wound. 

If  the  inflammation  be  suppurative,  it  will  keep  up  an  inflamma- 
tory or  suppurative  fever,  which  has  a  remittent  character,  with 
steep  curves  and  temporary  exacerbations  ;  this  is  due  to  prog- 
ress of  the  inflammation,  or  circumstances  favoring  absorption  of 
pus. 

To  recognize  this  fever,  it  is  important  to  try  the  temperature  at 
regular  hours  with  the  thermometer  ;  this  may  give  an  early  alarm 
to  the  surgeon  of  something  going  wrong  in  the  wound  ;  it  is  an 
aid  both  to  diagnosis  and  prognosis. 

In  contused  wounds  we  should  care  especially  for  free  escape  of 
secretion  by  drainage,  and  to  prevent  infection  of  the  wound  by 
anything  that  might  excite  decomposition,  or  at  all  events  to  limit 
this. 

Let  us  suppose  a  recent  contused  wound  with  moderate  destruc- 
tion of  the  soft  parts,  extravasation  of  blood,  and  disturbance  of 
circulation  in  the  adjacent  parts  ;  the  first  care  should  be  to  cleanse 
it  perfectly  of  foreign  bodies,  blood-clots,  and  tissue  fluids,  by 
passing  over  it  a  stream  of  a  two-per-cent.  solution  of  carbolic  acid  ; 
of  course  any  haemorrhage  is  to  be  arrested  ;  drainage-tubes  should 
be  applied,  the  wound  again  washed  with  a  four-per-cent.  solution 
of  carbolic  acid,  and  a  Lister's  dressing  applied. 

It  is  a  disputed  point  whether  sutures  should  be  used  in  such 
wounds  ;  if  the  contusion  be  considerable,  we  may  not  expect  union 
by  first  intention,  and  accurate  apposition  of  the  edges  would  be 
useless  or  even  injurious  ;  but  sutures  may  prevent  Avide  gaping  or 
excessive  retraction  of  the  flaps,  which  would  retard  union  ;  hence 
deep  sutures  may  be  introduced  to  fix  the  flaps  in  place  without  ac- 
curately approximating  them.  If  the  wound  be  small  and  only  the 
edges  contused,  the  contused  part  may  be  cut  off  and  united  as  in 
any  incised  wound. 

Slight  wounds,  under  Lister's  dressing,  run  their  course  almost 
without  reaction,  the  mortified  tissue  being  gotten  rid  of  by  molec- 
ular disintegration  and  absorption.  Gangrenous  shreds  do  not  ap- 
pear, the  crushed  parts  recover  by  restoration  of  the  circulation  or 
by  plasmatic  circulation,  and  entrance  of  wandering  cells  ;  this 
dead  tissue  is  also  consumed  by  the  granulation  tissue,  which  forms 
on  the  borders  of  the  living,  just  as  are  portions  of  dead  tissue  in- 
troduced into  the  abdomens  of  animals.  Under  such  circumstances, 
suppuration  may  be  slight  or  absent,  there  may  be  merely  a  mucous 


TREATMENT   OF   CONTUSED   WOUNDS.  187 

secretion  without  cells,  at  first  brownish-red,  later  yellowish,  and 
some  parts  may  unite  by  first  intention. 

If,  in  the  contusion,  there  has  been  extensive  crushing  and  tear- 
ing of  the  soft  parts  or  openings  into  the  joints  or  sheaths  of  the 
tendons,  fractures  of  the  bones,  etc.,  frequently  Lister's  dressing 
does  not  answer  the  purpose,  from  the  difticulty  of  cleansing  the 
wound  and  later  of  preventing  decomposition.  Frequently  such 
wounds  are  not  recent  when  they  come  under  treatment ;  they  may 
be  unclean  from  foreign  bodies  or  applications  of  arnica,  poultices, 
etc.  In  such  cases  it  is  well  not  to  try  Listerism,  but  to  treat  the 
wound  open  :  cleanse  it  carefully,  guard  against  retention  of  secre- 
tion, enlarging  the  skin-wound  if  necessary  ;  if  the  soft  parts  are 
undermined,  make  counter-openings  ;  cut  off  parts  incapable  of  liv- 
ing, and  wash  the  wound  with  a  six-  to  eight-per-cent.  solution  of 
chloride  of  zinc,  which  is  disinfectant  and  slightly  cauterant  ;  this 
gives  the  blood  a  red  hue  and  the  tissue  a  grayish-white  color. 
Apply  drainage-tubes  and  fill  the  pockets  with  some  charpie  or  pre- 
pared cotton  soaked  in  a  disinfectant  solution.  This  prevents  su- 
perficial adhesions  as  well  as  retention  of  the  secretions.  To  the 
wound  you  apply  plenty  of  charpie,  and  cover  the  whole,  far  beyond 
the  contusion,  with  compresses  also  soaked  in  disinfectant  (such  as 
acetate  of  alumina),  then  gutta-percha  paper  and  a  snug  bandage. 

The  dressing  should  be  changed  daily,  and,  if  there  is  much  dis- 
charge, twice  daily — else  the  disinfectant  will  not  suifice.  This 
dressing  also  supplies  moist  warmth,  which  has  a  favorable  effect 
on  the  previously-disturbed  circulation  ;  redness  and  oedematous 
swelling  of  the  edges  of  the  wound  diminish,  and  granulations 
develop.  Dressings  with  JBuroid's  fluid  are  cheaper  than  Lister''s 
dressing,  and  less  irritating  than  carbolic  solutions. 

Each  time  the  wound  is  dressed  it  should  be  carefully  washed 
and  examined  for  collections  of  pus.  If  the  escape  of  matter  be 
anywhere  impeded  the  opening  should  be  enlarged,  or  a  counter 
opening  made  by  passing  a  silver  catheter  or  a  flexible  metal  sound 
to  the  bottom  of  the  sinus,  then  cutting  down  on  it.  During  sup- 
puration the  wound  should  be  thus  dressed  ;  when  the  cavity  is 
filled  up  cicatrization  may  be  hastened  by  some  irritating  salve,  as 
of  red  precipitate,  iodoform,  etc. 

After  injuries  by  machinery,  railroad  accidents,  etc.,  there  may 
be  such  crushing  of  the  tissue  as  to  cause  primary  mortification  of 
the  skin  and  soft  parts.  The  muscles  are  crushed  to  a  pulp,  and 
with  the  extravasations,  etc.,  may  form  a  flaccid  bladder  communi- 
cating outwardly  by  a  small  wound  in  the  skin  ;  the  skin  being  very 
resistent  to  crushing  force,  as  is  observable  on  using  Chassaignac's 


188      CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS. 

'ecraseur,  it  may  be  so  compressed  as  to  be  bloodless  and  leathery, 
but  it  is  difficult  to  divide  it  completely  ;  where  the  crushing  has 
been  extensive,  but  the  opening  in  the  skin  is  small,  this  should  be 
enlarged  to  expose  the  cavity  for  treatment  ;  in  such  cases  open 
treatment  is  insufficient,  from  the  danger  of  decomposition  at  some 
point  of  the  dead  tissue  exposed  to  moisture  at  the  heat  of  the 
body.  Here  permanent  antiseptic  irrigation  may  be  resorted  to,  by 
dressing  as  above  described,  with  charpie  in  the  wound  and  cover- 
ing with  compresses,  only  not  applying  gutta-percha,  but  suspend- 
ing an  EsmarcKs  irrigator  so  that  BurovPs  solution  may  drop  on 
the  moist  compresses  and  keep  them  wet  ;  the  injured  part  being 
placed  on  a  rubber  cloth  so  that  the  superfluous  liquid  may  run 
from  it  into  a  vessel  under  the  bed  ;  constant  renewal  of  the  disin- 
fecting fluid  in  the  dressing  is  thus  secured.  This  plan  is  suited  for 
severe  injuries  of  the  hand  and  fingers.  If  the  wound  be  extensive, 
deep,  and  irregular,  it  is  well  to  lead  the  irrigation  through  the 
drainage-tubes  to  the  bottom  of  the  wound,  for  which  purpose  you 
may  let  one  or  two  of  the  chief  tubes  project  through  the  dressing 
and  connect  with  the  irrigator  ;  the  fluid  may  escape  through  an- 
other tube  or  through  the  wound.  When  the  apparatus  is  in  good 
Avorking  order,  it  requires  little  further  attention.  The  effect  is  very 
good,  the  necrosed  parts  being  quickly  detached  and  healthy  granu- 
lations developed.  Irrigation  also  acts  by  abstracting  heat  and  re- 
lieving pain,  and  is  very  acceptable  to  the  patient,  except  when  the 
bed  is  accidentally  wet.  It  is  best  suited  for  applying  immediately 
after  the  injury  ;  when  the  wound  has  cleaned  and  granulated,  this 
dressing  may  be  changed  for  simple  moist  dressing. 

The  results  from  this  treatment  are  very  favorable  as  compared 
with  those  by  old  methods.  Besides  the  slight  local  reaction  there 
is  absence  of  severe  general  infectious  disease  if  the  irrigation  be 
applied  early.  The  temperature  may  rise  high,  but  other  signs  of 
fever  are  absent. 

If,  from  improper  treatment,  decomposition  and  putrefaction 
have  started,  if  the  edges  of  the  wound  and  the  soft  parts  are 
swollen,  infiltrated  with  serum,  and  symptoms  of  general  infection 
are  present,  if  amputation  is  not  directly  indicated,  treatment  should 
be  preceded  by  energetic  disinfection  and  evacuation  of  the  septic 
matter.  This  is  to  be  done  by  opening  the  wound  to  its  full  extent, 
washing  with  a  four-per-cent.  solution  of  carbolic  acid,  and  rubbing 
with  sponges  ;  the  mortified  tissues  are  removed,  and  where  the 
skin  is  gangrenous  it  is  to  be  divided  to  where  it  is  healthy  ;  pock- 
€'ts  are  to  be  opened  ;  numerous  deep  punctures  should  be  made  in 
the  infiltrated  tissue  to  let  the  serum  escape,  according  to  Volk- 


TREATMENT   OF   CONTUSED   WOUNDS.  189 

mami's  plan  ;  then  the  whole  should  be  washed  and  rubbed  with  a 
four-pei"-cent.  solution  of  carbolic  acid,  and  I^uroic^s  solution  ap- 
plied on  compresses  and  irrigation  started. 

Even  when  contused  wounds  have  begun  to  suppurate  decompo- 
sition may  occur  from  retained  secretion.  This  is  shown  by  redness 
and  swelling  of  the  edges,  or  by  sudden  severe  pain  and  fever  ;  on 
examination  you  find  a  sensitive  spot,  on  pressing  which  thin  fetid 
pus  escapes  from  some  part  of  the  wound.  Often  there  are  several 
such  points,  or  the  suppuration  is  in  the  sheath  of  a  tendon  or  be- 
tween muscles,  and  we  have  a  long  sinus.  In  such  cases  counter- 
openings  are  indicated,  or  even  laying  open  the  whole  fistulous 
tract,  and  scraping  with  a  sharjD  spoon  the  relaxed  granulations,  and 
cauterizing  the  surface  with  a  concentrated  solution  of  chloride  of 
zinc.  In  such  cases  also  the  acetate  of  alumina  is  the  best  dressing, 
but  it  should  be  applied  at  least  once  daily. 

If  the  infiammation  be  diphtheritic  in  charactei',  with  hard  infil- 
tration, deep  incisions  should  be  made  to  prevent  gangrene,  and 
moist  warmth  applied  (compresses  moistened  with  hot  liurcno's  so- 
lution) to  break  down  the  infiltration  and  hasten  suppuration. 

This  is  the  only  reason  for  using  poultices,  which  were  formerly 
so  common,  because  they  retain  heat  better  than  hot-water  com- 
presses. They  should  be  banished  from  the  hospital  as  a  dirty 
dressing  with  many  objections  ;  in  private  i:)ractice,  where  their 
preparation  may  be  watched,  they  may  sometimes  be  employed  ; 
the  warmth  is  agreeable  to  the  patient. 

We  have  incidentally  mentioned  quiet  and  position  in  the  treat- 
ment ;  in  this  class  of  injuries  it  is  the  more  important,  as  excite- 
ment of  the  vascular  system  induces  congestion  of  the  injured  parts 
and  is  injurious.  Hence  not  only  should  the  injured  part  be  kept 
motionless,  but  the  whole  body  should  be  kept  quiet,  the  j^atient 
remaining  in  bed  and  avoiding  all  motion.  Mental  quiet  is  also 
most  desirable. 

When  possible,  the  injured  part  should  be  elevated.  Gravity  has 
some  effect  on  the  circulation,  as  you  may  see  by  letting  your  arm 
hang  relaxed  for  five  minutes,  when  the  hand  will  feel  heavy  and 
the  veins  on  its  back  be  filled  ;  but  if  you  hold  it  up  the  hand  grows 
white  and  smaller.  When  feeble  persons  lie  in  bed  their  faces  look 
fuller  than  after  they  have  been  up  some  time.  For  injuries  of  the 
hand  Volkmann  has  recommended  vertical  suspension  of  the  arm  ; 
the  same  treatment  may  be  applied  for  inflammations  of  the  leg. 
In  this  position  pain  is  speedily  lessened  ;  for  deep-seated  inflam- 
mations it  is  less  useful. 

Another  remedy  is  regular  compression  by  a  roller  bandage, 


190      CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS. 

which  may  be  applied  over  Lister's  dressing  ;  this  improves  the 
circulation  and  prevents  further  swelling  ;  rubber  bandages  rather 
loosely  applied  may  replace  muslin  for  this  purpose  ;  this  also  tends 
to  relieve  pain. 

The  most  important  rules  for  avoiding  accidental  complications 
of  wounds  are  prophylactic,  and  consist  in  rigid  antisepsis,  not  only 
in  treating  the  wound,  but  in  the  whole  care  of  the  patient.  The 
surgeon  should  see  to  the  disinfection  of  the  furniture  and  every- 
thino-  in  the  room,  to  the  ventilation  and  cleanliness,  and  to  the  re- 
moval of  old  dressings,  etc.  If  attention  be  merely  given  to  the 
wound,  results  will  be  unsatisfactory.  Instruments,  sponges,  dress- 
ings, etc.,  should  be  kept  constantly  disinfected.  For  hospitals  new 
sponges  should  be  cleaned,  disinfected,  and  kept  in  a  closed  glass 
vessel  in  a  four-per-cent.  solution  of  carbolic  acid,  which  should  be 
changed  every  week,  and  be  washed  again  in  carbolized  water  before 
using.  Catgut  and  silk  should  be  boiled  for  an  hour  in  a  four-per- 
cent, solution  of  carbolic  acid.  Carbolized  gauze  loses  its  strength 
after  a  time,  hence  should  be  prepared  fresh  frequently.  Gutta- 
percha paper,  the  instruments,  etc.,  should  be  washed  with  carbol- 
ized water  before  using.  Nurses  should  be  trained  to  consider 
antisepsis,  as  well  as  cleanliness,  second  nature. 

Speyicer  Wells,  the  ovariotomist,  demanded  that  physicians  wish- 
ing to  see  his  operations  should  not  have  visited  a  dissecting  or 
autopsy  room  for  some  days  previously,  hoping  thus  to  escape  in- 
fection from  their  clothing.  Danger  from  this  cause  may  probably 
be  avoided  by  washing  in  disinfectant  solutions  on  leaving  the  dis- 
secting or  autopsy  room.  It  is  proper  t^  remove  the  outer  clothing 
before  entering  the  sick-room,  as  infecting  germs  readily  adhere  to 
rough  cloth.  In  the  hospital  it  is  well  to  wear  a  linen  blouse  with 
the  sleeves  tight  at  the  wrist,  and  when  this  is  soiled  put  on  a  fresh 
one  ;  this  is  not  to  protect  the  clothes  of  the  surgeon,  but  to  guard 
against  infection. 

This  advice  is,  of  course,  applicable  to  any  kind  of  wound, 
whether  from  accident  or  operation.  You  cannot  be  too  exact  in 
observing  the  above  rules  ;  they  are  applicable  not  only  to  hospitals, 
but  just  as  much  so  to  private  practice. 

Cooling  drinks  and  medicines  and  proper  diet  should  be  pre- 
scribed :  if  a  remittent  fever  occurs,  rendering  the  patient  dull  and 
sleepless,  quinine  and  opium  may  be  beneficial.  If  the  fever  be 
slight,  give  nothing  ;  if  fever  increases  toward  evening,  two  five- 
grain  doses  of  quinine,  with  bicarbonate  of  soda,  may  be  given,  and 
the  eighth  of  a  grain  of  morphine  at  bedtime  ;  on  cessation  of  the 
fever  this  may  be  discontinued. 


LACERATED   WOUNDS.  191 

Now  a  few  words  about  lacerated  wounds,  by  which  we  mean 
those  where  there  is  a  division  of  the  soft  parts  and  the  skin  or  of 
the  latter  alone,  characterized  chiefly  by  the  irregular,  uneven  edges 
of  the  wound  ;  different  tissues  having  different  cohesiveness  and 
elasticity,  the  same  force  tears  some  more  readily  than  others,  and 
some  retract  more  than  others.  At  the  time  of  injury  the  pain  is 
severe,  but  soon  ceases,  as  the  nerves  have  been  torn  and  fail  to 
conduct.  Haemorrhage  is  usually  slight,  even  if  large  arteries  have 
been  ruptured  ;  this  is  due  to  the  mode  of  injury.  If  an  artery  be 
stretched  lengthwise,  the  intima  and  media  tear  first,  they  roll  up 
and  obstruct  the  calibre  ;  if  the  traction  continue,  the  tougher  ad- 
ventitia  is  drawn  out  into  a  solid  string,  which  finally  ruptures  in 
the  middle,  leaving  two  conical  ends,  plugged  within  by  a  mechan- 
ical obstruction  about  which  blood  quickly  coagulates.  Haemor- 
rhages from  ruptured  veins  may  be  much  freer,  because  their  ad- 
ventitia  is  much  weaker,  and  is  apt  to  be  torn  with  the  inner  mem- 
branes. 

Microscopic  examination  of  a  lacerated  wound  shows  that  it  is 
almost  always  the  intercellular  substance,  not  the  cells,  that  is  torn. 
The  destruction  is  less  than  in  contused  wounds,  hence  the  prognosis 
is  more  favorable  ;  the  wound  being  more  exposed,  there  is  less 
fear  of  injury  of  deep  tissues,  and  we  see  the  full  extent  of  injury. 
Healing  by  first  intention  is  not  rare,  as  the  edges  of  the  wound 
have  not  been  crushed,  and,  although  many  blood-vessels  may  have 
been  ruptured,  circumstances  are  favorable  for  plasmatic  circula- 
tion.] 

But  ruptures  are  not  always  exposed  ;  there  are  also  subcutane- 
ous ruptures  of  muscles,  tendons,  or  even  of  bones,  without  there  hav- 
ing been  any  contusion.  A  person  wishes  to  leap  a  ditch,  and  makes 
a  start,  but  fails  in  his  attempt ;  he  falls,  and  feels  a  severe  pain  in 
one  leg,  and  limps  on  it.  On  examination,  just  above  the  heel  (the 
tuberositas  calcanei),  we  find  a  depression  in  which  the  thumb  may 
be  laid  ;  the  motions  of  the  foot  are  imperfect,  especially  extension. 
What  has  happened  ?  The  tendo  Achillis  has  been  torn  from  the 
calcaneus  by  the  great  muscular  action.  The  same  thing  occurs 
with  the  tendon  of  the  quadriceps  femoris,  which  is  attached  to  the 
patella,  with  the  patella  itself,  which  may  be  torn  in  two,  with  the 
ligamentum  patellae,  with  the  triceps  brachii,  which  may  be  torn 
from  the  olecranon,  and  generally  carries  a  jDiece  of  the  latter  along 
with  it.  Here  you  have  a  few  examples  of  such  subcutaneous  rup- 
tures of  tendons  ;  I  have  seen  subcutaneous  rupture  of  the  rectus 
abdominis,  of  the  vastus  externis  cruris,  and  other  muscles.  These 
simple  subcutaneous  ruptures  of  muscles  are  not  serious  injuries  ; 


192      CONTUSED  AND  LACERATED  WOUNDS  OF  TEE  SOFT  PARTS. 

they  are   readily  recognized  by  the  disturbance   of   function,  by 
the  depression,  which  may  be  seen  and  still  better  felt,  which  at 


Fig.  40. 


Central  end  of 
a  torn  brach- 
ial artery. 


Fig.  41. 


Fig.  42. 


Tom-ont  middle  finger,  with  all  its         Arm  torn  out,  with  scapula 
tendous.  and  clavicle. 


LACERATED   WOUNDS.  I93 

once  occurs,  but  subsequently  is  masked  by  the  effused  blood.  The 
treatment  is  simple  :  rest  of  the  part,  placing  it  so  that  the  ruptured 
ends  may  be  brought  in  contact  by  relaxation  of  the  muscle,  cold 
compresses,  lead-water  lotions  for  several  days  ;  after  eight  or  ten 
days  the  patient  can  generally  rise  without  pain  ;  at  first  there  is 
a  connective-tissue  intermediate  substance,  which  soon  condenses  so 
much,  by  shortening  and  atrophy,  that  a  firm  tendinous  cicatrix 
forms  ;  the  course  is  just  the  same  as  in  subcutaneous  division  of 
tendons,  of  which  we  shall  speak  in  the  chapter  on  deformities. 

Functional  disturbances  of  any  considerable  amount  rarely  re- 
main ;  occasionally  there  is  some  weakness  of  the  extremity  and 
loss  of  delicate  movements,  especially  in  the  hand. 

For  such  subcutaneous  rupture  of  muscles  and  tendons  to  be 
caused  by  contusion,  the  crushing  force  would  have  to  be  very  great  ; 
such  a  contusion  would  probably  run  a  bad  course  ;  extensive  sup- 
purations and  necroses  of  tendons  might  be  expected.  Here,  again, 
you  see  how  varied  may  be  the  course  of  injuries  apjjareutly  the 
same,  according  to  the  mode  of  their  origin.  In  injuries  by  machin- 
ery there  is  often  such  a  wonderful  combination  of  crushing,  twist- 
ing, and  lacerating,  that  even  with  great  experience  it  is  very  diffi- 
cult to  give  any  accurate  prognosis  of  their  course.  The  favorable 
course  of  cases,  where  small  or  even  large  portions  of  a  limb  (as  the 
hand)  are  torn  off,  is  especially  worthy  of  mention.  I  have  seen  two 
cases  where  fingers  were  torn  off  ;  I  will  briefly  narrate  one  of 
them  :  a  mason  was  employed  on  a  scaffolding,  and  suddenly  felt  it 
giving  way  under  him  ;  from  the  roof  of  the  house  against  which 
the  scaffold  rested  there  hung  a  loop  ;  the  falling  man  grasped  this, 
but  only  succeeded  in  getting  the  middle  finger  of  the  right  hand 
through  the  loop  ;  he  hung  a  moment  and  then  fell  to  the  ground. 
Fortunately,  the  height  was  not  great,  and  he  was  not  injured,  but 
the  middle  finger  of  the  right  hand  was  gone  ;  it  was  torn  out  at  the 
joint  between  the  first  phalanx  and  the  metacarpal  bone,  and  it  still 
hung  in  the  loop.  The  two  tendons  of  the  flexors  and  that  of  the 
extensor  remained  attached  to  the  finger  ;  they  had  been  torn  off 
just  at  the  insertion  of  the  muscles  ;  the  man  dried  his  finger  with 
the  tendons,  and  subsequently  carried  it  in  his  purse  as  a  memento 
of  the  circumstance.  I  saw  a  similar  case  in  the  clinic  at  Zurich 
(Fig.  41).  Cure  resulted  without  much  inflammation  of  the  forearm, 
and  actually  no  treatment  was  required.  In  Zurich  I  saw  two  cases 
where  the  hand  was  torn  out  ;  in  one  case  there  was  enough  skin 
remaining  to  leave  the  healing  to  itself,  in  the  other  case  an  ampu- 
tation of  the  forearm  was  necessary.  Both  cases  terminated  favora- 
bly. In  war  it  is  not  very  rare  for  arms  and  legs  to  be  torn  from 
14 


194      CONTUSED  AND  LACERATED  WOUNDS  OF  THE  SOFT  PARTS. 

tlieir  sockets  by  large  cannon-balls.  I  have  also  seen  a  case  where 
a  boy  fourteen  years  old  had  the  right  arm  with  the  scapula  and 
clavicle  so  torn  from  the  thorax,  by  a  wheel  of  machinery,  that  it 
was  only  attached  at  the  shoulder  by  a  strip  of  skin  two  inches  wide 
(Fio-.  4:2).  The  axillary  artery  did  not  bleed  a  drop  ;  both  ends 
vv^ere  closed  by  torsion  (Fig.  40).  The  unfortunate  fellow  died 
soon  after  the  injury.  Tearing  out  of  entire  extremities  is  usually 
quickly  fatal. 


CHAPTER  V. 
SIMPLE  FRACTURES   OF  BOXES. 


LECTURE    XIV. 


Causes,  Different  Varieties  of  Fractures. — Symptoms,  Diagnosis. — Course  and  External 
Symptoms. — Anatomy  of  Healing,  Formation  of  Callus. — Source  of  the  Inflamma- 
tory Osseous  New  Formation. — Histology. 

Gentlemen  :  Hitherto  we  have  been  exclusively  oceupied  with 
injuries  of  the  soft  jDarts  ;  it  is  time  to  consider  the  bones.  You  will 
find  that  the  processes  that  Nature  excites  for  the  restoration  of  the 
parts  are  essentially  the  same  that  you  already  know ;  but  the  circum- 
stances are  more  complicated,  and  can  only  be  fully  understood  when 
you  are  perfectly  acquainted  with  the  mode  of  healing  in  the  soft 
parts.  Every  person  knows  that  bones  may  be  broken,  and  again  be 
firmly  united ;  this  can  only  be  done  by  bony  tissue,  as  you  will  at 
once  see;  hence  it  follows  that  new  bony  substance  must  be  formed; 
the  cicatrix  in  bone  is  usually  bone  ;  a  very  important  fact,  for,  if  this 
were  not  the  case,  if  the  broken  ends  only  grew  together  by  connec- 
tive tissue,  as  divided  muscles  do,  the  long  bones  particularly  would 
not  be  united  firmly  enough  to  support  the  body,  and  after  the  sim- 
plest fractures  many  men  would  be  cripples  for  life.  Still,  before  fol- 
lowing the  process  of  the  healing  of  bones  to  its  more  minute  details, 
a  study  that  has  always  been  pursued  with  great  zeal  by  surgeons, 
I  must  tell  you  something  about  the  origin  and  symptoms  of  simple 
fractures  ;  I  say  "  simple  or  svibcutaneous  fractures  "  in  contradistinc- 
tion to  those  accompanied  by  wounds  of  the  soft  parts. 

Man  may  even  come  into  the  world  with  broken  bones :  the  bones 
of  the  foetus  may  be  broken,  while  in  the  uterus,  by  abnormal  con- 
tractions of  that  organ,  or  by  blows  or  kicks  on  the  pregnant  abdomen, 
and  such  intra-uterine  fractures  generally  heal  with  considerable  dislo- 
cation ;  as  we  shall  see  in  other  instances,  the  vis  medicatrix  natures. 


196  SIMPLE   FRACTURES   OF  BONES. 

Is  a  better  pliysician  than  surgeon.  Of  course,  fractures  of  the  bones 
may  occur  at  any  age,  but  they  are  most  frequent  between  the  ages 
of  twenty-five  and  sixty  years,  for  the  following  reasons :  The  bones 
of  children  are  still  pliable,  and  hence  do  not  break  so  easily ;  if  a 
child  falls,  it  does  not  fall  heavily.  Old  people  have,  as  is  commonly 
remarked,  brittle,  friable  bones  ;  or,  anatomically  expressed,  in  old  age 
the  medullary  cavity  grows  larger,  the  cortical  substance  thinner ;  but 
old  persons  are  less  in  danger  of  fractures  of  the  bones,  because  their 
lack  of  strength  prevents  their  doing  hard  and  dangerous  work.  It  is 
during  the  age  when  men  are  most  exposed  to  hard  work  that  injuries 
generally  and  fractures  especially  are  most  liable  to  occur.  The  less 
frequency  of  fractures  among  women  is  due  to  the  variety  of  their 
occupation.  It  is  also  due  entirely  to  external  circumstances  that  the 
long  bones  of  the  extremities,  especially  of  the  right  side,  break  more 
frequently  than  those  of  the  trunk.  It  is  evident  that  diseased  bones, 
which  are  already  Aveak,  break  more  easily  than  healthy  ones ;  hence 
certain  diseases  of  the  bones  greatly  predispose  to  fractures,  especially 
the  so-called  English  disease,  "  rickets,"  which  is  due  to  deficient  de- 
posit of  lime-salts  in  the  bones,  and  only  occurs  in  children ;  also 
softening  of  the  bones  or  "  osteomalacia,"  which  depends  on  ab- 
normal dilatation  of  the  medullary  caA-ity,  and  thinning  of  the  cor- 
tical substance,  and  which  is,  to  a  great  extent,  accompanied  by 
a  "  fragilitas  ossium,"  and  even  by  total  softness  and  flexibility  of  the 
bones. 

As  special  causes  of  fractures,  we  have  the  two  following  :  1.  The 
action  of  external  forces,  the  most  frequent  cause ;  this  action  may 
\ary  in  the  following  ways :  the  force — for  instance,  a  blow  or  kick — 
meets  the  bone  directly,  so  that  it  is  crushed  or  broken  ;  or  the  bone, 
especially  a  long  bone,  is  bent  more  than  its  elasticity  permits,  and 
breaks  like  a  stick  that  is  bent  too  much ;  here  the  force  acts  indi- 
rectly on  the  point  of  fracture.  In  the  mechanism  of  the  latter  variety, 
instead  of  the  single  hollow  bone,  you  may  consider  a  whole  extremity 
or  the  entire  spinal  column  as  a  stick,  flexible  to  a  certain  extent,  and 
on  this  supposition  found  your  idea  of  the  indirect  action  of  the  force. 
Let  us  have  a  couple  of  examples  to  explain  this :  If  a  heavy  body  falls 
on  a  forearm  at  rest,  the  bones  are  broken  by  direct  force ;  if  a  person 
falls  on  the  shoulder,  and  the  clavicle  is  broken  obliquely  through  the 
middle,  this  is  the  result  of  indirect  force.  In  both  cases  there  is  usu- 
ally contusion  of  the  soft  parts ;  but  in  the  latter  case  it  is  more  or 
less  removed  from  the  point  of  fracture  ;  in  the  former  at  that  point, 
which  evidently  is  to  be  regarded  as  less  favorable.'' 

2.  Muscular  action  may,  though  rarely,  be  the  cause  of  fracture. 
As  I  already  indicated,  when  speaking  of  the  subcutaneous  rupture  of 


VARIETIES   OF   SIMPLE   FRACTURES.  I97 

muscles,  the  patella,  the  olecranon,  and  part  of  the  calcaneus  also,  may 
be  torn  off  by  muscular  action,  that  is,  obliquely  fractured. 

The  way  in  which  the  bones  break  under  these  varied  ajDplications 
of  force  varies,  but  some  types  have  been  formed  that  you  should 
know.  First,  we  distinguish  complete  and  incomplete  fractures. 
Incomplete  fractures  are  again  subdivided  into  fissures^  i.  e.,  clefts, 
tracks  ;  they  are  most  frequent  in  the  flat  bones,  but  occur  also  in  the 
long  bones,  especially  as  longitudinal  fissures  accompanying  other 
fractures ;  the  cleft  may  gape  or  appear  simply  as  a  crack  in  glass. 
Infraction^  or  bending,  is  a  partial  fracture,  which,  as  a  rule,  only 
occurs  in  very  elastic,  soft  bones,  and  especially  in  rachitic  children ; 
you  may  best  imitate  this  fracture  by  bending  a  quill  till  its  concave 
side  breaks  in.  In  children,  such  infractions  of  the  clavicle  are  not 
rare.  Wliat  we  mean  by  splintering  is  evident ;  the  most  frequent 
causes  are  machine-cutters,  sabre-strokes,  etc.  Lastly,  the  bone  may 
be  perforated  without  entire  solution  of  continuity,  as  by  a  punctured 
wound  through  the  scapula,  or  a  clean  shot  through  the  head  of  the 
Humerus.     The  latter  variety  of  injury  is  called  a  perforated  fracture. 

Complete  fractures  are  subdivided  into  transverse^  oblique,  longi- 
tudinal, dentate,  simple,  or  midtiple  fractures  of  the  same  bone,  com- 
minuted,'  all  of  these  expressions  explain  themselves.  Lastly,  we 
must  mention  that  persons  as  old  as  twenty  years  may  also  have  a 
solution  of  continuity  in  the  epiphyseal  cartilages,  although  this  is  rare, 
and  the  long  bones  break  more  readilj''  at  some  other  point. 

Frequently  it  is  easy  to  recognize  that  a  bone  is  broken,  and  a 
non-professional  person  may  make  the  diagnosis  with  certainty;  in 
other  cases  the  diagnosis  may  be  very  difficult,  and  occasionally  can 
only  be  a  probable  one. 

Let  us  take  up  the  symptoms  one  after  another.  First,  accustom 
yourself  to  examine  every  injured  part  accurately,  and  compare  it 
with  healthy  parts  ;  this  is  particularly  important  in  the  extremities. 
You  may  not  unfrequently  know  what  the  injury  is  by  simple  ob- 
servation of  the  injured  extremity.  You  ask  the  patient  how  it  hap- 
pened, having  him  undressed  meantime,  or,  if  this  be  painful,  have  his 
clothes  cut  off,  that  you  may  accurately  examine  the  injured  part.  The. 
manner  and  severity  of  the  injury,  the  weight  of  any  body  that  has 
fallen  on  the  part,  may  indicate  about  what  you  have  to  expect.  If 
you  find  the  extremity  crooked,  the  thigh  bent  outward,  for  instance, 
and  swollen,  if  suggillations  appear  under  the  skin,  if  the  patient  can- 
not move  the  extremity  without  great  pain,  you  may  with  certainty 
decide  on  a  fracture  ;  here  you  need  no  further  examination  to  decide 
on  the  simple  fact  of  a  fracture,  it  is  not  necessary  to  put  the  patient 
to  any  pain  on  this  account ;  you  have  only  to  examine  with  the 


198  SIMPLE  FRACTURES   OF  BOXES. 

hands  to  find  how  and  where  the  fracture  runs  ;  this  is  less  necessary, 
on  account  of  determining  the  treatment,  than  to  be  able  to  decide 
whether  and  how  recovery  will  result.  In  this  case  you  have  made 
the  diagnosis  at  a  glance,  and  in  surgical  practice  it  will  often  be  easy 
for  you  to  recognize  very  quickly  the  true  state  of  affairs,  when  you 
are  accustomed  to  use  your  eyes  thoughtfully,  and  when  you  have  ac- 
quired a  certain  habit  in  judging  of  normal  forms  of  the  body.  Never- 
theless, you  should  know  perfectly  how  you  arrived  at  this  sudden 
diao-nosis.  The  first  point  was  the  mode  of  the  injury,  then  the  de- 
formity ;  the  latter  is  caused  by  two  or  more  pieces  of  bone  (frag 
ments)  having  been  displaced.  This  dislocation  of  the  fragments  is 
due  partly  to  the  injury  itself  (they  are  driven  in  the  direction  that 
they  maintain,  from  the  bending  of  the  bone),  partly  to  the  muscular 
action  which  no  longer  affects  the  entire  bone,  but  only  a  part ;  the 
muscles  are  excited  to  contraction,  partly  by  the  pain  from  the  injury, 
partly  by  the  pointed  ends  of  the  bone  ;  for  instance,  the  upper  por- 
tion of  a  fractured  thigh-bone  is  elevated  by  the  flexors,  the  lower  por- 
tion is  drawn  up  near  or  behind  the  upper  fragment  by  other  muscles, 
and  thus  the  thigh  is  shortened  and  deformed.  The  swelling  is  caused 
by  the  effusion  of  blood  (we  speak  here  of  a  fracture  that  has  just  oc- 
curred) ;  the  blood  comes  chiefly  from  the  medullary  cavity  of  the 
bone,  and  also  from  the  vessels  of  the  surrounding  soft  parts  which 
have  been  crushed  or  torn  by  the  ends  of  the  bone  ;  it  looks  bluish 
through  the  skin,  if  it  works  up  to  the  skin,  as  it  gradually  does.  Tlie 
patient  can  only  move  the  extremity  with  great  pain  ;  the  cause  of 
this  disturhance  of  function  is  e^ndent,  we  need  waste  no  words  on 
it.  If  we  examine  each  of  the  above  symptoms  separately,  none  of 
them,  either  the  mode  of  injury,  the  deformity,  swelling,  efFusion  of 
blood,  or  functional  disturbance,  will  alone  be  evidence  of  a  fracture, 
but  the  combination  is  very  decisive  ;  and  you  will  often  have  to 
make  such  a  diagnosis  in  practice.  But  all  these  symptoms  may  be 
absent  when  there  is  fracture.  If  there  has  been  an  injiu-y,  and  none 
of  the  above  symptoms  are  well  developed,  or  only  one  or  other  of  them 
distinctl}'^  exists,  manual  examination  must  aid  us.  "\Miat  will  you 
feel  with  j-our  hands  ?  You  should  learn  this  thoroughly  at  once.  I 
so  often  see  practitioners  feel  about  the  injured  part  for  a  long  time 
with  both  hands,  causing  the  patients  unspeakable  pain,  and  after  all 
finding  out  nothing  by  their  examination.  By  the  touch  you  may 
perceive  three  things  in  fractures ;  1.  Abnormal  mohlUty,  the  only 
pathognomonic  sign  of  fracture  ;  2.  You  may  often  detect  the  course 
of  the  fracture,  and  often  whether  there  are  more  than  two  fragments ; 
3.  By  moving  the  fragments  you  will  often  experience  a  rubbing  and 
cracking  of  the  fragments  against  each  other,  the  so-called  "  crepita- 


SYMPTOMS   OF  SIMPLE  FRACTURES.  199 

tion^^  — strictly  to  crei^itate  means  to  crackle ;  this  is  a  sound,  and  still 
we  say,  we  feel  crepitation ;  it  is  no  use  to  object  to  this  ;  this  is  an 
abuse  of  the  word,  which  has  so  gone  into  practice,  however,  that  it 
cannot  be  rooted  out,  and  every  one  knows  what  it  means.  An  edu- 
cated touch  usually  feels  at  once  all  that  can  be  detected  by  the 
touch ;  hence  it  is  unnecessary  to  make  the  patient  suffer  long  under 
this  examination.  Crepitation  may  be  absent  or  very  indistinct ;  of 
course,  it  only  exists  when  the  fragments  can  be  moved,  and  when 
they  are  quite  near  each  other;  if  they  be  considerably  displaced 
laterally  or  be  drawn  far  apart  by  muscular  contraction,  or  if  there  be 
blood  between  the  fragments,  no  crepitation  can  be  felt,  and  it  is 
often  difficult  to  detect  when  the  bones  lie  deep.  Hence,  if  we 
detect  no  crepitation,  this,  in  opposition  to  all  the  other  symptoms, 
does  not  prove  that  there  is  no  fracture.  Still,  even  where  there  is  crep- 
itation, you  may  mistake  its  origin ;  you  may  have  a  feeling  of  fric- 
tion under  other  circumstances ;  for  instance,  the  compression  of  blood 
coagula  or  fibrinous  exudations  may  give  a  feeling  of  crepitation ; 
this  soft  crepitation,  which  is  analogous  to  plem-itic  friction,  you 
should  not  and  will  not  mistake  for  bony  crepitus  after  some  experi- 
ence in  examination ;  when  opportunity  offers,  I  shall  hereafter  call 
your  attention  to  other  soft  friction-sounds  which  occur  especially  in 
the  shoulder-joint  in  children  and  old  persons.  For  experienced  sur- 
geons, in  certain  fractures  severe  pain  at  a  fixed  point  is  enough  for  a 
correct  diagnosis,  especially  as  is  contusions  the  pain  on  grasping  the 
bone  is  mostly  diffuse,  and  rarely  so  severe  as  in  fracture.  If  we  are 
examining  an  extremity,  it  is  best  to  seize  it  with  both  hands  at  the 
susjDected  point,  and  attempt  motion  here  ;  this  manipulation  should 
be  firm,  but  not  rough,  of  course.  I  must  add  something  about  the 
dislocation  of  the  fragments ;  this  may  vary,  but  the  displacements 
may  be  divided  in  various  classes,  which  from  time  immemorial  have 
had  certain  technical  designations,  which  are  still  used,  and  which 
consequently  must  be  explained.  Simple  lateral  displacement  is 
called  dislocatio  ad  latus  ;  if  the  fragments  form  an  angle  like  a  half- 
broken  stick,  it  is  called  dislocatio  ad  axin.  If  a  fragment  be  rotated 
more  or  less  on  its  axis,  we  call  it  dislocatio  ad peripheriam  /  if  the 
broken  ends  be  shoved  past  each  other  vertically,  it  is  a  dislocatio  ad 
longitudinem.  Tlie  expressions  are  short  and  distinctive,  and  easily 
remembered,  especially  if  you  represent  to  yourselves  the  displace- 
ments by  diagrams. 

We  now  pass  to  a  description  of  the  course  of  healing  of  a  frac- 
ture. You  will  rarely  have  the  opportunity  of  seeing  what  happens 
when  no  bandage  is  applied,  as  the  patient  generally  sends  early  for 
a  surgeon.     But  occasionally  the  laity  undervalue  the  importance  of 


200  SIMPLE  FRACTURES  OF  BONES. 

the  injury ;  several  days  pass  before  the  pain  and  duration  of  the 
affection  at  last  cause  the  patient  to  apply  to  a  surgeon.  In  such 
cases,  besides  the  symptoms  of  fracture  already  given,  you  find  great 
oedema,  and  in  some  few  cases  inflammatory  redness  of  the  skin  about 
the  point  of  fracture ;  under  such  circumstances  the  examination  may 
be  very  difficult ;  occasionally  the  swelling  is  so  considerable  that  an 
exact  diagnosis  as  to  the  course  and  variety  of  the  fracture  is  out  of 
the  question.  Hence  the  earlier  we  see  a  fracture  the  better.  The 
subsequent  external  changes,  at  the  point  of  fracture  may  best  be 
studied  on  bones  that  lie  superficially,  and  which  cannot  be  sur- 
rounded ^\ith  a  bandage,  as  on  fracture  of  the  clavicle.  After  seven 
to  nine  days,  the  inflammatory  osdematous  swelling  of  the  skin  has 
subsided,  the  extravasated  blood  has  run  through  its  discolorations 
and  goes  on  to  reabsorption,  and  a  firm,  immovable,  hard  tumor  lies 
around  the  point  of  fracture  ;  this  is  larger  or  smaller  according  to  the 
dislocation  of  the  fragments ;  it  is,  as  it  were,  poured  around  the  frag- 
ments, and  in  the  course  of  eight  days  becomes  as  hard  as  cartilage; 
this  is  called  callus.  Pressure  on  it  (the  fragments  can  with  difficult}'- 
be  felt  through  it)  is  painful,  though  less  so  than  jireviously ;  subse- 
quently the  callus  becomes  absolutely  firm,  the  broken  ends  are  no 
longer  movable,  the  fracture  may  be  regarded  as  healed ;  for  the  clav- 
icle this  requires  three  weeks,  in  smaller  bones  a  shorter,  and  in  larger 
ones  a  much  longer  time.  But  this  does  not  end  the  external  changes ; 
the  callus  does  not  remain  as  thick  as  it  was ;  for  months  or  years 
it  grows  thinner,  and,  if  there  was  no  dislocation  of  the  fragments, 
after  a  time  no  trace  of  the  fracture  will  remain ;  if  there  was  a  dis- 
location that  could  not  be  reduced  by  treatment,  the  ends  of  the  bone 
unite  obliquely  and  after  absorption  of  the  callus  the  bone  remains 
crooked. 

To  find  out  the  changes  that  take  place  in  the  deeper  j)arts,  how 
the  fractured  ends  unite,  we  try  experiments  on  animals.  We  make 
artificial  fractures  on  dogs  or  rabbits,  apply  a  dressing,  kill  the  ani- 
mals at  various  stages,  and  then  examine  the  fracture  ;  we  may  thus 
obtain  a  perfect  representation  of  the  process.  These  experiments 
have  been  made  innumerable  times.  The  results  have  always  been 
essentially  the  same ;  but,  if  we  speak  of  rabbits  alone,  there  are 
certain  variations  which,  as  proved  by  numerous  experiments,  depend 
on  the  amount  of  dislocation  and  of  extravasation  of  blood.  Hence, 
before  showing  you  a  series  of  such  preparations,  I  must  give  you  the 
result  of  these  investigations,  and  exempHfy  them  by  a  few  diagrams ; 
then  you  will  hereafter  readily  understand  the  slight  modifications. 

We  shall  first  confine  ourselves  to  what  we  can  see  Avith  the  naked 
eye  and  a  lens.     If  you  examine  a  rabbit's  leg  three  or  four  days  after 


FORMATION   OF   CALLUS. 


201 


the  fracture,  and,  while  it  is  firmly  held  in  a  vice,  saw  the  bone  longi- 
tudinally, you  find  the  following  :  the  soft  parts  about  the  fracture  are 
swollen  and  elastic ;  the  muscles  and  subcutaneous  cellular  tissue  loolc 
fatty  ;  tlie  swollen  soft  parts  form  a  spindle-shaped,  not  very  thick 
tumor  about  the  seat  of  fracture.  About  the  broken  ends  we  find 
some  dark  extravasated  blood,  and  the  medullary  cavity  at  the  same 
point  is  somewhat  infiltrated  with  blood.  The  amount  of  this  escaped 
blood  varies,  being  sometiines  very  slight,  again  considerable.  At  the 
point  of  fracture  the  periosteum  may  be  readily  recognized,  and  is  in- 
timately connected  with  the  other  swollen  soft  parts  (which  are  the 
seat  of  plastic  infiltration).  Occasionally  it  is  somewhat  detached 
from  the  bone  at  the  point  of  fracture.  The  whole  thing  looks  about, 
as  follows  (Fig.  43) : 

Fig.  44. 


Fig.  43. 


..-6 


mm 

Lonaitufliual  section  of  a  fracture  of  a 
rabbifs  bone,  four  clays  old ;  a,  ex- 
travasated blood  ;  b,  swollen  soft  parts 
external  callus  ;  c,  periosteum. 


Diac:ram  of  a  longitudinal  section  of  a 
fifteen-day-old  fracture  of  a  lougbone  ; 
(/,  internal  callus  ;  b,  inner,  c.  outer 
layer  of  ossification  of  the  external 
callus ;  d,  new  periosteum.  The  di- 
mensions of  the  callus,  in  proportion 
to  the  entire  lack  of  dislocation  of 
the  fragments,  are  represented  as  far 
too  great,  but  this  facilitates  the  pi-e- 
liminary  understanding  of  the  case. 


If  we  now  examine  a  fracture  in  a  rabbit  after  ten  or  twelve  days, 
we  find  that  the  extravasation  has  either  entirely  disappeared,  or  that 
only  a  slight  amount  remains.  I  will  not  raise  the  question  as  to 
whether  it  has  been  entirely  reabsorbed,  or  has  partly  organized  to 
callus.  The  spindle-shaped  swelling  of  the  soft  i^arts  has  mostly  the 
appearance  and  consistence  of  cartilage,  and  has  also  the  same  micro- 
scopical characteristics;  in  the  medullary  cavity  also  we  find  young 


202  SIMPLE   rRACTURES   OF   BONES. 

cartilage  formations  in  the  vicinity  of  the  fractm-e.  The  broken  bone 
sticks  in  this  cartiLage  as  if  the  two  fragments  had  been  dipped  in 
sealing-wax  and  stuck  together ;  the  periosteum  is  still  tolerably  dis- 
tinct in  the  cartilaginous  mass,  but  it  is  swollen,  and  its  contours  are 
indistinct.  Although  there  are  traces  of  ossification  even  now,  they 
do  not  become  very  decided  or  evident  to  the  naked  eye  for  some  days 
(perhaps  the  fourteenth  to  the  twentieth  day  after  the  fracture). 
Tlien  we  see  the  following  (Fig.  44)  : 

In  the  vicinity  of  the  fracture  there  is  young  soft  bone :  1.  In  the 
medullary  cavity  (a).  2.  Immediately  on  the  cortical  layer  (b),  and 
some  distance  up  and  down  beneath  the  periosteum,  which  has  disap- 
peared in  the  whole  spindle-shaped  callus  tumor.  3.  In  the  periphery 
of  the  callus,  which  is  still  mostly  cartilaginous  (c).  The  periosteum 
which  previously  lay  within  the  callus  has  now  disappeared ;  in  its 
place  a  thickened  layer  of  tissue  has  formed  on  the  outside  of  the 
callus,  which  represents  the  periosteum  (d).  The  young  bone-sub- 
stance is  soft,  white,  and  in  it  we  may  see  a  kind  of  structure ;  for 
small  parallel  pieces  of  bone,  corresponding  to  the  transverse  axis  of 
the  bone,  may  be  distinctly  seen,  especially  on  examination  with  a 
lens.  The  cartilaginous  caUus  formed  from  the  surrounding  soft  parts, 
into  which  the  periosteum  also  has  been  partly  transformed,  now 
forms  an  enclosed  whole,  and  ossifies  entirely,  partly  from  Avithout  (c), 
partly  from  within  (J),  till  finally  the  ends  of  the  bone  stick  in  bony, 
as  they  previously  did  in  the  cartilaginous  callus.  This  bony  callus, 
which  consists  entirely  of  spongy  bone-substance,  is  called  by  Du- 
puytren  '•''provisional  callus.''''  As  it  is  completed,  the  bone  is 
usually  firm  enough  to  be  again  capable  of  function  ;  but  the  callus 
does  not  remain  in  its  present  condition  any  more  than  a  recent  cica- 
trix of  the  soft  parts  does.  A  series  of  changes  occurs  in  it  in  the 
course  of  months  or  j-ears,  for  up  to  this  point  you  may  still  compare 
the  union  to  that  b}'  sealing-wax,  which  is  not  a  true  organic  union. 
So  far  the  firm  cortical  substance  is  only  united  by  loose  young  bone- 
substance  ;  the  medullary  cavity  is  plugged  with  bone ;  the  healing 
is  not  3^et  solid  ;  Nature  does  far  more.  We  shall  now  study  the 
subsequent  changes ;  they  are  confined  to  the  spongy  substance 
of  the  callus.  At  a  certain  time  this  ceases  to  increase,  and  then 
changes,  by  reabsorption  of  the  bony  substance  that  has  formed  in 
the  medullary  caA^ty  (Fig.  45),  and  by  the  disappearance  of  a  great 
part  of  the  external  callus.  Meantime,  formation  of  new  bone  has 
commenced  between  the  fractured  cortical  layers,  so  that  this  has 
become  solid  by  the  time  the  external  and  internal  callus  disap- 
pears. This  comiecting  bony  substance  between  the  fragments  grad- 
ually increases  in  density,  to  such  an  extent  that  it  becomes  as  hard  as 


UNION   OF  FRACTURES, 


203 


Fia.  45. 


four  weeks.  Progressive  real] 
Boiption  of  the  callus.  Restora- 
tion of  the  medullary  cavity, 
natural  size  ;  after  Gurlt. 


Except  the  regeneration 


the  bone  in  the  normal  cortical  substance.  In  case  there  has  been 
little  or  no  displacement  of  the  fragments,  tlie  bone  is  thus  so  fully 
restored  that  we  can  no  longer  determine 
the  point  of  fracture,  either  on  the  living 
person  or  the  anatomical  preparation. 

The  above  changes  occur  in  a  Ions: 
bone  of  a  rabbit,  where  there  has  been 
little  displacement,  in  about  twenty-six 
or  twenty-eight  weeks,  but  in  the  long 
bones  of  man  last  much  longer,  so  far  as 
we  can  judge  from  preparations  that  we 
accidentally  have  the  opportunity  of  ex- 
amining. 

The  entire  jDrocess,  so  excellently  con- 
trived by  Nature,  is  essentially  the  same 
as  what  we  observe  in  the  normal  devel- 
opment of  the  long  bones  ;   for  there,  too,    Loncitucllnal  section  of  a  fractured 
.  ^  .  bone  from  a  ral)bit,  after  twenty- 

the    same  reabsorptlOn    and   condensation         four  weeks.     Progressive  reab- 

take  place  in  the  medullary  canal  and  the 

cortical  layers  of  the  long  bones,  as  we 

have  just  studied  in  formation  of  callus. 

of  nerves,  no  such  complete  restoration  of  a  destroyed  part  takes 

place  in  any  other  part  of  the  human  body  as  we  have  seen  occurs 

in  the  bones. 

I  must  still  add  a  few  remarks  about  the  healing  of  flat  arid  spongy 
bones.  In  the  case  of  the  first,  which  we  see  most  fi-equently  in  the 
healing  of  fissures  of  the  cranial  bones,  the  development  of  provi- 
sional callus  is  very  slight,  and  occasionally  appears  to  be  entirely 
wanting.  In  the  scajDula,  where  dislocation  of  small,  or  half  or 
wholly  detached  fragments  is  more  apt  to  occur,  external  callus  forms 
more  readily,  although  even  here  it  never  becomes  very  thick.  On  the 
union  of  spongy  bones,  too,  in  which,  as  a  rule,  there  is  also  Ijut  little 
dislocation,  there  is  less  development  of  external  callus  than  in  the 
long  bones ;  while,  on  the  other  hand,  the  cavities  of  the  spongy  sub- 
stance in  the  immediate  vicinity  of  the  fractvu-e  are  filled  with  bony 
substance,  of  which  part,  at  least,  subsequently  disappears. 

As  may  readily  be  imagined,  the  conditions  will  be  somewhat 
more  complicated  when  the  ends  of  the  bone  are  much  dislocated,  or 
when  fragments  are  entirely  broken  off  and  displaced.  In  such  cases 
there  is  such  a  rich  development  of  callus,  partly  from  the  entire  sur- 
face of  the  dislocated  fragments  and  from  the  medullary  cavity,  and 
partly  in  the  soft  parts  between  the  fragments,  that  for  some  distance 
all  the  fragments  are  embedded  in  a  bony  mass,  and  organically  glued 


204 


SIMPLE  FRACTUKES   OF   BONES. 


together.     Tlie  larger  the  circle  of  irritation  from  the  dislocated  frag- 
ments, the  more  extensive  the  formative  reaction. 

In  man  we  most  frequently  have  the  opportmiity  of  seeing  callua 
formation  in  greatly  dislocated  fractures  of  the  clavicle,  where  it  is 
very  evident  that  the  extent  of  the  new  formation  of  bony  substance 
is  directly  proportional  to  the  amount  of  dislocation.  You  may  read- 
ily understand  how,  in  this  way,  with  extensive  formation  of  neo- 
plastic bone-substance,  there  may  be  perfect  firmness,  even  with  great 
deformity  at  the  point  of  fracture.  Still,  one  would  hardly  believe, 
without  satisfying  himself  on  the  point,  from  preparations,  that  with 
time,  even  in  such  cases.  Nature  has  the  power  of  restoring,  not  only 
the  outward  shape  of  the  bone  (except  the  curvature  and  rotation), 
but  also  the  medullary  cavity,  by  reabsorption   and   condensation. 


Fie.  46. 


Pia.  47. 


fracture  of  the  tibia  of  a  rabbit,  with 
great  dislocation,  with  extensive 
formation  of  callus,  after  27  days. 
Natural  size,  aftcir  Skntsch. 
(OuHVs  Fractures,  vol.  i.,  p.  270.) 


Old  united  oblique  fracture  of  a  human  tibia  ; 
the  ends  of  the  fragments  have  been 
rounded  off  by  absorption,  the  extermil 
callus  reabsorbed;  formation  of  the  me- 
dullary cavity  incomplete.  Size  dimin- 
ished.    GurU,  1.  c,  p.  287. 


Numbers  of  points,  nodules,  inequalities  and  roughnesses  of  all  sorts, 
that  are  formed  on  the  young  callus  in  recent  cises,  so  disappear  in 
the  course  of  months  and  years,  that  in  their  place  there  is  only  lefl 
some  dense,  compact,  cortical  substance. 


FORMATION   OF  NEW   BONE. 


205 


It  will  now  be  interesting  to  investigate  the  true  origin  of  the 
ocwly-fonned  bony  substance  ;  is  it  produced  by  the  bone  itself,  by 
the  periosteum,  by  the  surrounding  soft  parts,  or  is  the  extravasated 
blood  transformed  into  bone,  as  was  believed  by  old  observers? 
Must  formation  of  cartilage  always  precede  that  of  bone,  or  is  this 
unnecessary?  These  questions  have  received  various  answers,  till 
quite  recently.  To  the  periosteum,  especially,  great  power  of  pro- 
ducing bone  has  at  one  time  been  ascribed,  at  another  denied.  In 
what  follows,  I  will  briefly  give  you  the  results  of  my  investigations 
on  this  subject. 

The  new  formation  that  results  from  the  fracture  occurs  in  the 
medulla  and  Haversian  canals  of  the  bone,  in  the  periosteum,  and  in- 
filtrated in  the  adjacent  muscles  and  tendons ;  possibly  the  extrava- 
sated blood  may  also  have  something,  but  \ery  little,  to  do  with  the 
formation  of  the  callus ;  a  large  extravasation  is  disturbing  here,  as  in 
healing  of  wounds  of  the  soft  parts,  for  part  of  it  must  be  organized, 
while  the  remainder  is  absorbed.  The  inflammatory  new  formation 
here,  also,  at  first  consists  of  small  round  cells,  which  increase  greatly 
in  number,  and  infiltrate  the  tissues  mentioned,  and  then  almost  take 
their  place.  Before  following  the  fate  of  this  cell-formation  further,  I 
must  briefly  consider  its  course  in  the  Haversian  canals.  The  cell-in- 
filtration in  the  connective  tissue  of  the  medullary  cavity  offers 
nothing  peculiar,  except  that  the  fat-cells  of  the  medulla  disappear 
in  the  mass  as  the  wandering  cells  take  possession  of  the  territory. 
Suppose  the  following  figure  (Fig.  48)  to  represent  the  surface,  or  the 
fractured  surface,  of  a  bone  on  which,  as  you  know,  the  Haversian 
canals  open;  in  these  canals  lie  blood-vessels,  surrounded  hy  some 
connective  tissue. 

If   this  bony  surface  be   in  the  vicinity  of   a  fracture,  numerous 

Fio.  4S. 


Diafrram  of  a  longitudinal  section  tViroiigh  the  cortical  suhstance  of  a  Ions:  bone.  a.  8iirf;:ce : 
b.  Haversian  canals,  with  blood-vessels  and  connective  tissue;  c.  periosteum.  Maf;nified 
40J  diameters. 


208 


SIMPLE   FRACTURE  OF  BONES. 


cells  first  come  between  the  connective  tissue  in  tlie  Haversian  canals ; 
should  this  cell-infiltration  be  very  rapid,  it  would  entirely  compress 
the  blood-vessels,  and  cause  the  death  of  the  bone,  a  process  which 
we  shall  hereafter  leam.  But,  if  the  cell-increase  in  these  canals  goes 
on  slowly,  their  walls  are  gradually  absorbed,  as  it  would  appear,  by 
the  inflammatory  new  formation  itself;  the  canals  are  dilated,  the  cells 
fill  them,  and  at  the  same  time  the  blood-vessels  increase  by  forming 
loops. 

From  the  observations  of  CohnJieim,  we  must  suppose  tliat  in 
inflammation  of  bone,  also,  the  young  cells  in  the  Haversian  canals 
are  not  newly  formed,  but  are  Avhite  blood-cells  escaped  from  the  ves- 
sels.    This  has  no  effect  on  the  subsequent  course. 

Now,  let  us  turn  to  the  changes  of  form  that  we  observe  in  the 
osseous  tissue.  As  the  connective  tissue  of  the  osseous  canals  is  con- 
tinuous, both  with  the  periosteum  and  medulla,  the  cell-infiltration 
into  the  bone,  periosteum,  and  medulla,  is  also  continuous.  The  cause 
of  the  atrophy  of  bone  along  the  walls  of  the  Haversian  canals, 
which  takes  place  in  this,  as  in  most  other  new  formations  in  the  bone, 
is  difficult  to  explain;  the  disappearance  of  the  connective  tissue  and 
muscular  substance,  as  well  as  of  other  soft  structures,  when  the  in- 
flammatory new  formation  occurs  in  them,  is  less  strange ;  but  it  is 
truly  remarkable  that  hard  bony  substance  should  thus  be  dissolved. 
This  process  might  be  represented  by  the  following  diagram  (Fig.  49) : 


Fia.  49. 


C»: 


Diaijram  of  inflammatory  new  formation  in  the  Haversian  canal-",    a,  surface ;   b  h.  Haversian 
canals,  dilated,  filled  with  cells  and  new  vessels ;  c,  periosteum.    Magnified  400  diameters. 

You  see  that  the  dilatation  of  the  osseous  canals  is  not  regular, 
but  of  uneven  widths ;  the  bone  looks  as  if  gnawed  out ;  this  is  not 
necessarily  so,  the  atrophy  of  the  bone  may  be  more  regular ;  accord- 
ing to  my  idea,  these  irregularities  result  from  the  collection  of  cells 
in  groups,  or  from  looping  of  the  vessels,  which  press  against  the 


FORMATION   OF   CALLUS.  207 

oone  and  cause  its  atrophy.  VircJiow  and  others  believe  that  these 
protuberances  correspond  to  the  nutrient  territory  of  certain  bone- 
cells,  which  in  this  process  aid  in  reabsorption  of  the  bone.  I  think  I 
have  refuted  this,  by  showing  that  even  dead  portions  of  bone  and 
ivory  are  also  affected  by  the  inflammatory  new  formation  ;  we  shall 
speak  more  of  this  when  treating  of  pseudarthrosis.  At  present  it  is 
not  known  how  the  lime-salts  are  dissolved  in  this  process  ;  I  think 
probably  the  new  formation  in  the  bone  develops  lactic  acid,  which 
changes  the  carbonate  and  phosphate  of  lime  into  soluble  lactate  of 
lime,  and  that  this  is  taken  up  and  removed  by  the  vessels  ;  but  this 
is  only  hypothesis.  It  would  also  be  possible  for  the  organic  basis  of 
the  bone,  the  so-called  osseous  cartilage,  to  be  first  dissolved  by  the 
inflammatory  neoplasia,  and  then  there  would  be  a  breaking-down  of 
the  chalky  substance,  whose  molecules  would  be  subsequently  re- 
moved, even  if  undissolved.  Although  I  have  conversed  with  many 
chemists  and  physiologists  on  this  point,  none  of  them  have  given  me 
a  simple  explanation  of  this  process,  nor  could  they  indicate  any  mode 
of  experimenting  that  might  aid  in  solving  the  question. 

In  the  above  diagrams,  if  we  suppose  the  fractured  surface  where 
there  is  no  periosteum,  in  place  of  the  surface  of  the  bone,  you  will 
understand  how  the  new  formation  (the  young  callus)  grows  from  it 
out  of  the  Haversian  canals  as  above  described,  similar  neoplasia 
from  the  other  fragment  meets  and  unites  with  it,  as  in  healing  of 
the  soft  parts.  It  is  evident  that  the  bone  through  which  the  inflam- 
matory neoplasia  thus  grows  must  become  porous,  from  the  reabsorp- 
tion that  takes  place  on  the  walls  of  the  canal ;  if  you  macerate  a 
bone  in  this  stage,  till  the  young  neoplasia  decomposes,  the  dry  bone 
will  appear  rough,  porous,  gnawed,  while  young  bone-substance  is 
deposited  on  it  and  in  its  medullary  cavity.  I  must  again  repeat 
that  in  drawings  and  descriptions  we  have,  for  the  sake  of  clearness, 
made  the  callous  formation  appear  much  more  extensive  than  it  really 
is,  and  that  here,  as  in  wounds  of  the  soft  parts,  the  regenerative 
processes  do  not  usually  extend  very  far  or  very  deep,  but  are  merely 
enough  for  healing,  rarely  in  excess.  In  this  whole  explanation  we 
have  not  mentioned  the  bone-cells  or  stellate  bone-corpuscles ;  I  am 
convinced  that  they  have  as  little  to  do  with  these  processes  as  the 
Gxed  connective-tissue  cells,  and  that  the  bone-substance,  like  the  soft 
parts,  is  dissolved  by  a  certain  amount  of  inflammation,  and  replaced 
by  new. 

So  far  we  only  know  the  neoplasia  in  the  state  where  it  consists 
essentially  of  cells  and  vessels,  as  the  aoft  parts  do  under  the  samo 
circumstances ;  if  there  was  retrogression  to  a  connective-tissue  cica- 
trix here  as  there  is  there,  we  should  h-^.TO  no  solid  bone  formed,  but  a 


208 


SIMPLE  FRACTURE   OF   BONES. 


connective-tissue  union,  lyseudarthrosu  (from  ■\^ev6r]q^  false  ;  ap&poyaig, 
joint),  a  false  joint ;  we  shall  hereafter  describe  these  exceptional  cases. 
Under  normal  circumstances  the  neoplasia  noAv  ossifies,  as  you  already 
know.  This  ossification  may  either  occur  directly  or  after  the  inflamma- 
tory neoplasia  has  been  transformed  to  cartilage.  You  know  that  both 
of  these  modes  are  seen  in  normal  growth  of  the  bone  ;  direct  ossifica- 
tion of  young  cell-formation,  for  instance,  in  the  periosteum  of  the 
gro\\ino-  bone,  or  formation  of  cartilage  with  subsequent  ossification, 
as  at  first  in  the  entire  skeleton  and  in  gi'owth  of  the  bones  length- 
wise. Callus  from  fi-actures  varies  greatly  in  this  resjject  in  men  and 
animals.  In  rabbits  the  callus  is  always  changed  to  cartilage  before 
ossification,  as  it  also  is  in  children.  In  old  dogs  the  callus  usually 
ossifies  directly,  as  in  the  human  adult ;  we  are  far  from  knowing  the 
causes  of  these  differences.  To  obtain  a  histological  representation 
of  these  processes,  let  us  return  to  our  former  diagram  (Fig.  49)  ;  now 
imagine  that  the  cells,  lying  in  the  spaces  caused  by  reabsorption  in 
the  Haversian  canals  and  surface  of  the  bone,  soon  ossify  and  first  fill 
these  spaces  (Fig.  50),  then  collect  on  the  surface  and  in  the  medulla, 


Fig.  50. 


Diagram  of  ossification  of  inflammatory  neoplasia  on  the  surface  of  the  bone  and  in  the  Haver- 
sian canals.    Osteoplastic  periostitis  and  ostitis.    Magnified  400  diameters. 


and  thus  form  the  external  and  internal  callus.  Periostitis  and 
ostitis,  which  lead  chiefly  or  exclusively  to  the  formation  of  new 
bone,  we  call  osteoplastic ;  in  the  present  case  the  callus  is  the  result 
of  this. 


FORMATION   OF  CALLUS. 


209 


As  previously  remarked,  the  periosteum  is  used  up  in  the  neopla- 
sia and  in  ossifying  callus,  in  its  place,  externally  around  the  callus,  a 
thick  connective-tissue  layer  develops,  from  which  new  periosteum 
is  formed.     I  will  show  you  a  few  more  preparations  in  explanation 

Fia.  51. 


Artificially-injected  external  callus,  ol'sliprht  thickness,  on  the  surface  of  a  rabbit's  tibia,  in  the 
vicinity  of  a  five-day-old  fracture.  Loujjitudiual  section — a,  callus  ;  b,  boue.  Magnified  20 
diameters. 


Fig.  52. 


of  the  process  in  the  periosteum.     You  see  (Fig.  51)   the  peculiar 
course  of  the  vessels  almost  at  right  angles  to  the  bone,  which  enter 

the  bone  through  the  young  callus. 
The  ossification  of  the  callus  begins, 
mantle-like,  around  these  vessels,  and 
the  little  columns  which  first  appear 
in  the  external  callus  are  thus  formed 
(see  remarks  on  Fig.  44). 

You  have  a  good  representation  of 
the  formation  of  external  (periosteal) 
and  internal  (endosteal)  callus  in  the 
following  (incomplete)  transverse  sec- 
tion of  the  tibia  of  a  dog,  from  the 
immediate  vicinity  of  an  eight-day- 
old  fracture,  in  which  j^ou  must  also 
observe  the  vessels  of  the  cortical  sub- 
stance, which  are  considerably  dilated 
as  compared  with  normal  (Fig.  52). 

Lastly,  observe  the  following  prepa- 
ration. It  is  an  eight-day-old,  already 
ossified,  external  callus  on  the  surface 
of  the  tibia  of  a  dog,  magnified  250 
times  (Fig.  53). 

If  we  now  view  the  process  as  a 
whole,  we  see   that  the   cell  infiltra- 
tion in  the  bone  itself,  as  well  as  in  all  the  surrounding  parts,  aids 
in  the  formation  of  callus,  and  that  hence  the  periosteum  plays  no  ex- 
clusive osteoplastic  i'ole.     This  might  have  been  concluded  a  jyrioi'i, 
]5 


Artificially-injected  transverse  section  of 
the  tibia  of  a  dog,  from  the  immedi- 
ate vicinity  of  an  ei<,'ht-day-old  frac- 
ture, a,  internal  callus ;  6,  external ; 
cc,  cortical  layer  of  the  bone.  Magni- 
fied 20  diameters. 


210  SIMPLE   FRACTURE    OF   BOXES. 

because  if  the  ]:>eriosteum  alone  formed  the  external  callus,  as  was 
formerly  supposed,  the  portions  of  the  bone  free  of  periosteum,  as 
those  places  wheie  tendons  are  attached  to  the  bone,  could  form 
no  callus ;  this  is  directly  contradicted  by  observation.  In  normal 
growth,  also,  the  periosteum  does  not  by  any  means  play  the  im- 
jjortant  part  ascribed  to  it  in  the  formation  of  bone  ;  for  we  may  just 
as  correctly  regard  the  layer  of  }Oung  cells  lying  on  the  surface  of 
the  bone,  and  extending  into  the  Haversian  canals,  as  belonging  to 
the  bone,  as  to  refer  it  to  the  periosteum. 


Fig.  53. 


m  ^'^'y//^:-'^:^^/: 


Ossif\-in<?  callus  on  the  smrface  of  a  hollow  bone,  near  a  fracture.  Loufritudinal  section  majmified  800. 
As  appears,  the  ossifying  callus  is  not  hmited  to  the  periosteum,  but  extends  in  betweeu  the 
muscles. 


Recent  investigations  concerning  tl  e  grouth  of  hones,  made  by 
J.  Wolffs  render  it  very  probable  tliat  they  increase  in  all  directions 
by  interstitial  deposit  of  young  osseous  tissue,  and  hence  that 
growth  by  apposition  through  the  epiphyseal  cartilages  and  perios- 
teum can  no  longer  be  regarded  as  the  sole  source  of  increase  in 
length  and  thickness ;  such  a  mode  of  growth  is  placed  beyond   a 


TREATMENT   OF  FRACTURES.  211 

doubt  by  Wegner^s  excellent  work  on  the  osteoplastic  action  of  phos- 
phorus on  growing  bones. 

I  will  not  conceal  from  you  that  the  view  which  I  have  obstinately 
maintained,  that  the  boue-cells  in  new  osseous  formations  do  not  pro- 
liferate, but  remain  quite  passive,  is  much  disputed ;  since  Co/in- 
heim  has  shown  the  passiveness  of  the  stabile  connective-tissue  cor- 
puscles in  inflammation,  there  does  not  seem  so  much  strangeness 
about  my  view,  which  was  advanced  years  ago,  and  was  founded  on 
numerous  observations ;  still,  the  explanation  of  the  preparations  in 
question  is  not  simple  enough  to  permit  only  one  view.  Recently, 
by  very  careful  investigations  about  the  histological  changes  diiring 
the  transformation  of  provisional  into  definitive  callus,  Lossen  has  tried 
to  show  that  the  bone-cells  in  the  former  take  an  active  part  in  the 
formation  of  vascular  canals  in  the  latter  by  enlarging  and  changing 
position.  I  can  agree  with  this  entirel}  without  abandoning  the 
above  views,  for  the  provision-callus  is  like  the  young  osteophytes  of 
calcified  connective  tissue,  like  certain  boundary-layers  between  car- 
tilage and  bone.  I  have  no  doubt  that  the  cells  of  this  "  osteoid  car- 
tilage" (  Yirchoic),  like  the  cells  of  hyaline  cartilage,  proliferate  to 
true  bone.  But  this  is  not  the  place  to  enter  more  deeply  into  the 
liistological  details,  which,  great  as  is  their  intrinsic  intfirest,  have  no 
essential  influence  on  the  definitive  formation  of  the  new  development 
of  bona 


LECTURE    XV. 

Treatment  of  Simple  Fractures.— Reduction. — Time  for  applying  the  Dressing,  its 
Choice. — Plaster  of  Paris  and  Starch  Dressings,  Splints,  Permanent  Extension.— 
Retaining  the  Limb  in  Position.— Indications  for  removing  the  Dressings 

We  shall  pass  at  once  to  the  treatment  of  simple  oi  subcutaneous 
fractures,  especially  fractures  of  the  extremities,  for  these  are  by  far  the 
more  frequent,  and  they  particularly  require  treatment  by  dressings. 
while  those  of  the  head  or  trunk  are  to  be  treated  less  by  dressings 
than  by  appropriate  position,  as  is  taught  in  the  lectures  on  special 
surgery  and  in  the  surgical  cHnic. 

The  indications  we  have  to  consider  are,  simply  to  remove  any 
dislocations  and  to  keep  the  fractured  extremity  in  the  correct  ana 
tomical  position  till  the  fracture  is  healed. 

First,  the  fragments  are  to   be   replaced;   sometimes   this   may 


212  SIMPLE  FRACTURE  OF  BONES. 

be  unnecessary,  as  when  there  is  no  dislocation,  for  instance,  in  some 
fractures  of  the  ulna,  fibula,  etc.  In  other  cases  it  is  very  difficult,  and 
cannot  always  be  done  perfectly.  The  obstacles  to  the  reposition  ma}- 
be  in  the  position  of  the  fragments  themselves  ;  one  fragment  may  be 
wedged  into  another,  or  a  small  fragment  lies  between  the  chief  ones, 
so  that  the  latter  cannot  be  brought  together  accurately ;  fractures 
of  the  lower  articular  extremity  of  the  humerus  are  very  obstinate  in 
this  respect,  for  small  fragments  may  be  so  dislocated  that  neither 
flexion  nor  extension  of  the  elbow-joint  can  be  performed  perfectly ; 
hence  its  functions  remain  permanently  impaired.  Muscular  con- 
traction forms  a  second  obstacle  to  the  reposition  of  the  fragments ; 
the  patient  involuntarily  contracts  the  muscles  of  the  broken  limb, 
thus  rubs  the  fragments  together  or  presses  them  into  the  soft  parts, 
causing  severe  pain ;  this  muscular  contraction  is  occasionally  almost 
tetanic,  so  that,  even  by  great  force,  it  is  hardly  possible  to  overcome 
th-e  opposition.  Indeed,  formerly  these  difficulties  were,  to  some  ex- 
tent, insurmountable;  and,  although  attempts  were  now  and  then 
made  to  attain  the  object  by  dividing  tendons  and  muscles,  it  was 
often  only  possible  to  attain  an  imperfect  reposition.  All  these  diffi- 
culties were  at  once  removed  by  the  introduction  of  chloroform  as  an 
anaesthetic.  Now,  in  all  cases  where  we  do  not  readily  succeed  in 
reposition,  we  anesthetize  the  patient  vnih.  chloroform,  till  his  mus- 
cles are  perfectly  relaxed,  and  we  can  then  usually  place  the  frag- 
ments in  position  without  difficulty.  Some  surgeons  go  so  far  as  to 
use  chloroform  in  almost  all  cases  of  fracture,  partly  for  the  examina- 
tion, partly  for  the  application  of  the  dressing.  This  is  unnecessary, 
and  may  even  prove  very  unpleasant,  for  some  persons,  especially  those 
m  the  habit  of  drinking,  at  a  certain  stage  of  the  anaesthesia  are 
affected  with  spasmodic  contractions  of  the  extremities,  so  that,  in 
spite  of  being  carefully  held  by  strong  assistants,  they  rub  the  frac- 
tured ends  against  each  other  with  fearful  force,  and  we  must  be  very 
careful  that  a  sharp  fragment  does  not  pierce  the  skin.  This  should 
not  frighten  you  from  using  chloroform  in  fractures,  when  it  is  neces- 
sary, but  simply  warn  you  against  being  too  free  with  it.  The  meth- 
od of  reposition  is  usually  as  follows :  The  fractured  part  is  grasped 
by  two  strong  assistants  at  the  joints  above  and  below  the  point  of 
fracture,  and  regular,  quiet  traction  employed,  while  the  surgeon 
holds  the  extremity  at  the  point  of  fracture,  and,  by  gentle  pressure, 
attempts  to  force  the  fragments  into  position.  All  sudden,  impul- 
sive, forced  traction  is  useless,  and  should  be  avoided.  Here  you 
have  to  notice  two  technical  expressions ;  we  term  the  traction  on 
the  lower  part  of  the  extremity,  extension^  that  on  the  upper  part, 
wunter-extension.     In  fractures,  these  are  both  made  bv  tlie  hands 


TREATMENT  OF  FRACTURES.  213 

wliile  in  dislocations  we  must  occasionally  resort  to  different  mechan- 
ical appliances.  By  the  above  method  accurate  reposition  will  only 
be  impossible  when,  from  excessive  swelling  or  from  peculiarly  un- 
favorable dislocation  of  the  fragments,  we  are  unable  to  correctly 
recognize  the  variety  of  the  displacement. 

From  our  present  ideas,  which  are  based  on  a  large  number  of 
observations,  the  sooner  reposition  is  made  after  the  occurrence  of 
the  fracture,  the  better ;  we  then  at  once  apply  the  bandage.  This 
was  not  always  the  belief,  but  formerly  the  adjustment  of  the  frac- 
ture and  the  application  of  the  dressing  were  delayed  till  the  disappear- 
ance of  the  swelling,  which  almost  always  occurs  if  a  dressing  is  not 
at  once  applied.  It  was  feared  that  under  the  pressure  of  the  dress- 
ing the  extremity  might  mortify,  and  the  formation  of  callus  would 
be  hindered ;  with  certain  cautions  in  the  application  of  the  dress- 
ing, the  former  "may  very  readily  be  avoided,  and  there  is  little 
truth  in  the  latter  belief.  Regarding  the  choice  of  the  dressing  also, 
surgeons  have  of  late  reached  an  almost  unanimous  opinion.  It  may 
he  regarded  as  a  rule,  that  a  solid,  firm  dressing  should  he  applied  as 
early  as  p>ossihle  in  all  cases  of  simple  suhcutaneous  fractures  of  the 
extremities ;  this  may  be  changed  altogether  two  or  three  times,  but 
in  many  cases  does  not  need  renewal.  This  mode  of  dressing  is 
called  the  immovable  or  fixed,  in  contradistinction  to  the  movable 
dressings,  which  must  be  renewed  every  couple  of  days,  and  are 
only  provisional  dressings. 

There  are  several  varieties  of  firm  dressings,  of  which  the  most 
serviceable  are  the  plaster  of  Paris,  starch,  and  liquid  glass.  I  shall 
lirst  describe  the  plaster  dressing,  and  show  its  application,  as  it  is 
the  one  most  frequently  used,  and  answers  all  requirements  in  a  way 
that  can  scarcely  be  improved. 

Plaster  of  Paris  Bandage. — After  adjustment  of  the  fragments, 
the  broken  limb  is  extended  and  counter-extended  by  two  assistants, 
then  one  or  more  layers  of  wadding  applied  over  the  point  of  fracture, 
and  over  parts  where  the  skin  lies  directly  over  the  bone,  as  over  the 
crest  of  the  tibia,  the  condyles,  and  malleoli.  Now  it  is  best  to  en- 
velop the  limb  with  a  new  fine  flannel  roller-bandage,  so  as  to  make 
regular  pressure  on  it,  and  cover  all  parts  that  are  to  be  surrounded 
by  the  plaster-bandage.  In  hospital  and  poor  practice,  where  we  can- 
not always  have  flannel,  we  may  use  soft  cotton  or  gauze  bandages. 
Now  comes  the  application  of  the  plaster-bandages  prepared  for  the 
purpose ;  the  plaster-bandage  that  I  here  have  is  cut  from  a  very  thin 
gauze-like  stuff;  it  is  prepared  by  sprinkling  finely-powdered  plaster 
(modelling  plaster)  over  the  unrolled  bandage  and  then  rolling  it.  In 
private  practice  a  number  of  these  bandages  of  various  sizes  may  be 


214  SIMPLE  FRACTURE   OF   BONES. 

prepared  beforeliand  and  kept  in  a  well-closed  tin  box.  Here  m  the 
hospital,  where  these  plaster-bandages  are  much  used,  they  are  pre- 
pared two  or  three  times  a  week.  This  bandage  you  place  in  a  basin 
of  cold  water  and  let  it  soak  through,  then  apply  it  like  any  roller- 
bandage  to  the  extremity  prepared  as  above  described.  Three  or  at 
most  foiu-  thicknesses  of  this  plaster-bandage  suffice  to  give  the  dress- 
ing the  requisite  finnness.  In  about  ten  minutes  good  plaster  be- 
comes stiff  enough  for  us  to  lay  the  extremity  loose  on  the  bed ;  in 
half  an  hour  or  an  hour,  the  dressing  becomes  as  hard  as  stone  and 
quite  dry ;  the  time  required  for  hardening  depends  partly  on  the 
quality  of  the  plaster,  partly  on  how  much  you  have  moistened  the 
bandage.  After  many  comparisons  with  other  modes  of  applying  the 
plaster-bandage,  I  have  found  this  the  most  practical ;  but  I  must 
mention  some  modifications  of  the  vay  of  handling  the  plaster  and  of 
the  material  of  the  bandage.  For  instance,  we  may  rub  the  plaster 
into  the  common  muslin  or  flannel  bandages,  which  makes  the  dress- 
ing somewhat  heavier  and  firmer ;  but  this  is  not  necessary  and  the 
loose  gauze  is  very  much  cheaper  than  muslin-bandage.  If  the  band- 
age does  not  appear  sufficiently  firm,  we  may  apply  a  layer  of  plaster- 
paste  over  the  dressing ;  this  plaster-paste  is  to  be  made  with  water, 
and  spread  on  the  bandage  very  quickly  with  the  hand  or  a  spoon  ;  it 
should  not  be  prepared  till  we  wish  to  use  it,  as  it  stiffens  very  quick- 
ly. The  plaster-dressing  as  made  with  roller-bandages  was  first  in- 
troduced by  a  Dutch  surgeon,  3fathysen  /  this  method  was  first  pub- 
lished in  1832  ;  but  it  has  only  become  well  kno^vn  since  1850 :  it  has 
been  spread  tlu-ough  Germany  chiefly  by  the  Berlin  school.  A  differ- 
ent mode  of  applying  the  plaster-dressing  is  by  different  strips  of 
bandage ;  Pirogoff  first  hit  on  this  method  from  lack  of  bandages 
in  the  army ;  all  kinds  of  material  were  cut  into  the  shape  of  splints, 
then  drawn  through  thin  plaster-paste  and  laid  on  the  broken  limb, 
then  the  whole  Avas  coated  with  plaster-paste  and  a  firm  capsule  was 
thus  made.  Subsequently  the  same  surgeon  made  a  special  method 
of  this ;  he  cut  old  coarse  sail-cloth  into  certain  patterns  for  each  limb, 
and  applied  it  in  the  above  manner.  Lastly,  the  so-called  many-tailed 
bandage  of  Scultetns  was  used  in  the  same  way  as  a  plaster-bandage. 
The  foundation  of  the  bandage  has  also  been  modified  in  various 
ways ;  it  has  even  been  used  without  wadding  or  any  under-bandage, 
the  whole  hmb  being  simply  covered  with  oil  so  that  the  plaster- 
bandage,  being  applied  directly,  might  not  adhere  to  the  skin  by  the 
fine  hairs.  Others  have  employed  thick  layers  of  wadding  without 
iny  under-bandage.  Lastly,  thin  wooden  splints  or  strips  of  tin  have 
been  lately  used  in  it,  as  we  shall  hereafter  see ;  this  may  have  certain 
advantages  in  fenestrated  bandages. 


TREATMENT   OF   FRACTURES.  215 

I  have  intentionally  represented  all  these  modifications  of  the 
plaster-bandage  as  only  exceptionally  useful,  all  of  them  having  cer- 
hiin  objections  as  compared  with  the  method  first  described.  A  more 
careful  criticism  of  these  modifications  here  would  lead  us  too  far. 

For  persons  unskilled  in  the  matter,  the  removal  of  the  plaster 
bandage  is  quite  diflBcult,  but  you  may  see  that  any  of  my  nurses  will 
do  it  with  astonishing  quickness.  It  is  simply  done  as  follows:  with 
a  sharp,  strong  garden-knife  we  divide  the  plaster-bandage,  not  per- 
pendicularly but  rather  obliquely,  as  far  as  the  under-bandage,  then 
remove  the  bandage  entire,  like  a  shell ;  we  may  also  employ  the 
plaster-scissors  proposed  by  Szymanowski  or  those  of  JBruns.  We 
use  this  capsule  in  some  other  cases  as  a  provisional  dressing. 

Starch-Bandages. — Before  plaster-bandages  Avere  known,  we  had 
in  the  starch-bandage  an  excellent  material  for  the  immovable  dressing. 
'Hie  starch-bandage  was  perfected  and  introduced  chiefly  by  the  Belgi- 
an surgeon  Seutln  (f  1862) ;  it  is  only  during  the  last  twelve  years 
that  it  has  given  place  to  the  plaster-dressing,  but  it  is  still  used  oc- 
casionally. The  application  of  the  wadding  and  under-bandage  is  the 
same  as  in  the  plaster-dressing,  but  then  we  apply  splints,  cut  from 
moderately  thick  j^asteboard  and  softened  in  water,  to  the  limb,  and  fas- 
ten them  on  with  bandages  thoroughly  soaked  in  starch-paste ;  we  now 
apply  wooden  splints  till  the  dressing  has  hardened,  which  at  the  ordi- 
nary temperature  requires  about  twenty-four  hours.  Compared  to  the 
plaster-dressing  this  has  the  disadvantage  of  hardening  much  more 
slowly  ;  we  may  improve  this  somewhat  if  we  use  gutta-percha  splints 
instead  of  pasteboard,  these  maj''  be  softened  in  hot  water,  and 
adapted  to  the  extremity.  Gutta-percha  bands,  such  as  are  used  in 
factories,  are  very  useful  as  splints.  It  cannot  be  denied  that  the 
introduction  of  gutta-percha  into  surgery  is  to  be  regarded  as  a  great 
advantage  ;  but  it  is  too  costly  to  be  used  in  practice  for  every  simple 
fr?,cture,  althougli  thick  splints  of  this  material  harden  even  quicker 
than  plaster.  The  dressing  with  roller-bandages  prepared  with  plas- 
ter is  so  cheap  aiul  firm  that  it  will  certainly  not  be  displaced  again 
by  starch-bandages,  now  that  it  has  been  introduced  into  practice. 

Instead  of  plaster,  solutions  of  dextrine,  pure  white  of  e^g,  or 
simple  mixture  of  flour  and  water,  were  formerly  employed;  they 
have  all  gone  out  of  use,  but  it  is  well  for  you  to  know  the  usefulness 
of  these  substances,  which  are  in  every  house,  and  which  we  may 
well  employ  as  provisional  dressings. 

Liquid-glass  Dressings. — Instead  of  starch,  we  may  employ  the 
liquid  glass  of  the  shops  (silicate  of  potash).  On  applying  the  dress- 
ing, we  paint  this  on  the  muslin-bandages  with  a  large  brush,  after 
having  made  a  substratum  of  wadding  as  above  described.    The  liquid 


216  SIMPLE   FRACTURE   OF   BONES. 

glass  dries  quicker  than  starch,  but  not  so  soon  as  plaster,  nor  does  it 
become  as  bard  as  tbe  latter;  this  dressing  does  for  fractures  with  no 
tendency  to  displacement ;  if  we  wish  to  fix  dislocated  fragments  of  bone 
by  the  liquid-glass  dressing,  we  must  strengthen  it  by  applying  spUnts. 

I  doubt  not  the  time  will  soon  come  when  every  country  physician 
will  always  keep  a  few  plaster-splints  ready  prepared ;  in  spite  of 
Ihem,  provisional  dressinr/s  remain  useful.  These  consist  or  band- 
ao-es,  compresses,  and  splints,  of  various  materials.  You  may  make 
splints  of  thin  boards,  shingles,  cigar-boxes,  pasteboard,  tin,  leather, 
firmly-plaited  straw,  the  bark  of  trees,  etc.,  and,  for  bandages,  must 
often  content  yourselves  with  old  rags,  muslin,  torn  into  strips  and 
sewed  together;  hence,  in  the  practical  courses  on  bandaging,  it  is 
necessary  for  you  to  learn  to  make  use  of  the  most  varied  materials. 

It  is  not  our  intention  here  to  introduce  to  you  every  thing  that 
may  be  used  in  the  way  of  dressing,  but  I  must  still  speak  briefly  of 
a  few  things.  As  may  be  readily  seen,  the  object  of  the  splints  is  to 
make  the  bone  immovable  by  supporting  it  firmly  on  various  sides ; 
this  may  be  attained  by  external,  internal,  anterior,  and  posterior, 
narrow  wooden  splints;  we  may,  how'ever,  employ  hollow  splints, 
so-called  gutters.  Hollow  splints  are  only  good  when  made  of  plia- 
ble material,  as  leather,  thin  sheet-iron,  wire-gauze,  etc. ;  an  absolutely 
stifi",  hollow  splint  would  only  do  for  certain  persons.  Besides  these 
mechanical  aids,  there  is  another  method  of  keeping  broken  limbs  in 
position,  namely,  permanent  extension.  This  is  partictdarly  indicated 
in  cases  where  there  is  great  tendency  to  shortening,  to  dislocatio  ad 
longitiidinem.  Attempts  have  been  made  to  attain  this  extension  by 
attaching  w^eights  by  various  mechanical  contrivances,  by  continu(^d 
traction  made  bj^  weights  hung  to  the  injured  limb,  by  the  double- 
inclined  plane,  where  the  weight  of  the  leg  is  used  as  tlie  extending 
weight.  Since,  during  the  past  two  years,  I  have  unexpectedly  seen 
such  excellent  effect  from  permanent  extension  with  weights  in  pain- 
ful contractions  at  the  hip  and  knee  joints,  I  am  compelled  to  believe 
that  this  method  may  also  eventually  prove  very  serviceable  for  the 
gradual  adjustment  of  dislocated  fragments  of  bone.  Among  the 
arrangements  of  this  nature  with  which  I  am  acquainted,  V.  Dum- 
rcicher''s  so-called  railroad  apparatus  best  fulfils  the  object  of  perma- 
nent extension,  but  it  is  too  costly  and  complicated  to  come  into 
extensive  use  in  private  practice ;  it  is,  doubtless,  the  intention  of  the 
inventor  to  employ  it  cliiefly  in  cases  where  the  dislocation  is  difficult 
to  overcome.  [Dr.  Gurdon  Buck^s  apparatus  for  fractm-ed  thigh  is 
about  as  efficacious  and  much  simpler.]  The  double-inclined  plane, 
represented  by  a  thick  roller-cushion  applied  uudei  the  hollow  of  the 


TREATMENT  OF  FRACTURES.  217 

Knee,  may  occasionally  be  employed  as  a  suitable  fixation  apparatus 
in  fracture  of  tlie  neck  of  the  femur  in  old  persons. 

We  must  still  mention  some  auxiliary  appliances  which  we  have 
to  employ  to  keep  the  broken  limb  in  good  position  after  it  has  been 
dressed ;  for  the  upper  extremity,  in  most  cases,  a  simple,  properly* 
applied  cloth,  a  7)iitella,  or  sling,  in  which  the  arm  is  laid,  suffices. 
Patients  with  fractured  arm  or  forearm  may  be  permitted  to  go  about 
with  a  plaster-bandage  and  a  sling  during  the  entire  treatment,  with- 
out interfering  with  the  favorable  healing. 

For  keeping  broken  lower  extremities  in  position,  there  are  a 
number  of  mechanical  aids,  of  which  the  following  are  the  most 
serviceable :  sand-hags^  narrow  sacks  filled  with  sand,  about  the  length 
of  the  leg ;  these  are  placed  both  sides  of  the  firm  dressing,  so  that 
the  Umb  may  not  move  from  side  to  side ;  for  the  same  purpose  we 
may  use  long,  three-sided  pieces  of  wood,  cut  prismatically,  which  are 
laid  together,  so  as  to  form  a  gutter.  For  some  cases  a  sack,  loosely 
filled  with  chafi"  or  oats,  is  sufficient ;  we  make  a  hollow  in  it  length- 
wise, and  the  leg  is  to  be  placed  in  this.  If  we  desire  firmer  supports, 
we  uie  fracture-boxes,  narroAv,  long,  wooden  boxes,  open  at  the  upper 
end,  so  that  the  leg  may  be  placed  in  them ;  and  the  sides  are 
made  to  turn  down,  so  that  the  extremity  may  be  carefully  inspected, 
without  moving  it;  the  elevation  of  these  fracture -boxes  may  be 
suited  to  the  convenience  of  the  patient.  Lastly,  we  must  mention 
the  swing,  which  is  usually  made  with  a  gallows,  or  stro'ng  bow, 
that  is  brought  over  the  foot  of  the  bed,  and  to  which  the  limb  is 
suspended  in  any  sort  of  a  fracture-box,  or  hollow  splint  [or  Dr. 
JVat/ian  Smit/i''s  anterior  splint],  so  that  it  may  swing  about;  in 
restless  patients  especially,  this  has  certain  advantages.  All  these 
apparatuses,  which,  although  more  rarely  employed  than  formerly, 
are  still  occasionally  useful,  you  must  learn  to  apply;  you  will  have 
opportunity  for  this  in  the  surgical  clinic.  Of  late  we  rarely  apply 
these  apparatuses  in  the  lower  extremity,  as  my  former  assistant. 
Dr.  His,  who  has  brought  the  application  and  elegance  of  the 
plaster-bandage  to  an  extraordinary  state  of  perfection,  applies  a 
well-padded  wooden  splint,  three  or  four  inches  wide,  to  the  under 
side  of  the  leg,  making  it  reach  somewhat  below  the  heel  and  as 
high  as  the  knee,  or,  in  fractures  of  the  thigh,  as  high  as  the  middle 
of  the  thigh.  The  hmb  lies  firmly  on  this  board,  if  the  mattress  be  not 
too  imeven  ;  if  we  wish  to  attain  still  greater  firmness,  we  may  lay  a 
board  the  width  of  the  bed  over  the  lower  third  of  the  mattress,  and  on 
this  place  the  hmb,  with  its  plaster-dressing  and  supporting  splint.  In 
the  numerous  double  fractures  of  both  lower  extremities  that  came  lo 
the  Zurich  hospital,  this  supporting  apparatus  did  excellent  service. 


218  SIMPLE   FRACTURE   OF   BONES. 

The  old  form  of  plaster-moulds  has  been  receutlj'  strongly  advo- 
cated again  by  Dr.  31.  Midler;  we  have  tried  it  again,  but  it  bears  no 
comparison  with  the  plaster-bandage. 

Seutin  tried  to  increase  the  advantages  of  firm  dressings  by  giving 
aids  that  might  enable  patients  with  fractured  lower  limbs  to  go 
about  to  some  extent.  For  instance,  a  patient  with  a  broken  leg 
may  have  a  broad  leather  strap  passing  over  the  shoulder,  and  buckled 
just  above  the  knee,  so  that  the  foot  will  not  touch  the  floor,  and  then 
let  him  go  on  crutches.  But  I  advise  you  not  to  carry  these  experi- 
ments with  your  patients  too  far;  at  all  events,  I  only  allow  my 
patients  to  make  such  attempts  three  weeks  after  the  occurrence  of 
the  fracture,  otherwise  oedema  readily  occurs  in  the  broken  limb,  and 
some  patients  are  so  clumsy  in  the  use  of  crutches,  that  they  are  apt 
to  fall,  and,  although  this  ma}^  onl}'  cause  slight  concussion  of  the 
limb,  it  is  still  injurious. 

Lastly,  we  have  to  discuss  how  long  the  dressing  should  be  left 
on,  and  the  causes  that  might  induce  us  to  remove  it  before  the  cure 
is  complete.  The  decision  as  to  whether  a  dressing  is  too  tightly 
applied  is  entirely  a  matter  of  experience ;  the  following  symptoms 
must  guide  the  surgeon :  If  there  be  swelling  of  the  lower  part  of 
the  limb,  as  of  the  toes  or  fingers,  which  are  usually  left  exposed,  if 
these  parts  become  bluish  red,  cold,  or  even  senseless,  the  dressing 
should  be  removed  at  once.  If  the  patient  complains  of  severe  pain 
under  the  dressing,  it  is  wxll  to  remove  it,  even  if  we  can  see  nothing 
to  cause  it.  In  judging  of  the  exhibitions  of  pain,  we  should  know 
the  patients ;  some  always  complain,  others  are  very  indolent,  and 
p.how  their  feelings  but  little ;  however,  it  is  better  to  reapply  the 
bandage  several  times  uselessly  than  once  to  neglect  its  removal  at 
the  right  time.  I  cannot  too  strongly  urge  you  always  to  visit,  with- 
in twenty-four  hours  at  most,  every  patient  to  whom  you  appl}'  a  fixed 
dressing ;  then  your  patient  will  certainly  not  come  to  grief,  as  un- 
fortunately too  often  happens,  from  the  carelessness  and  laziness  of 
his  surgeon.  A  series  of  cases  has  been  published  where,  after  the 
application  of  a  firm  dressing,  the  afi'ected  limb  mortified,  and  re- 
quired amputation ;  from  these  cases  it  was  decided  that  firm  dress- 
ings were  always  improper,  while  the  fault  was  chiefly  due  to  the 
surgeon.  Just  think  how  little  trouble  we  have  in  treating  fractures 
now,  compared  to  former  times,  when  the  splints  had  to  be  renewed 
every  three  or  four  days  ;  now  j'ou  need  only  appl}'^  a  dressing  once 
But  you  must  not  think  you  have  got  rid  of  all  trouble  in  the  appli 
cation  of  dressings.  The  application  of  the  firm  dressing  requires 
just  as  much  practice,  dexterity,  and  care,  as  did  dressing  with 
splints.     If  you  are  first  called  to  a  fracture  when  it  is  two  or  three 


TREATMENT   OF  FRACTURES.  219 

days  old,  when  there  is  already  considerable  inflammatory  swelling", 
you  may  ev^en  then  apply  the  firm  dressing,  but  must  apply  it  more 
loosely,  and  with  plenty  of  wadding.  This  dressing  will  be  too  loose, 
and  should  be  renewed  in  ten  or  twelve  days,  when  the  swelling  has 
left  the  soft  parts.  It  will  chiefly  depend  on  the  looseness  of  tlie 
bandage,  and  the  greater  or  less  tendency  to  dislocation,  when  and 
how  often  the  dressing  should  be  removed  during  the  treatment. 
Swelling,  if  not  accompanied  by  considerable  contusion,  is  no  contra- 
indication to  a  carefully-applied  firm  bandage  ;  nor  do  large  or  small 
vesicles,  full  of  clear  or  slightly-bloody  serum,  present  any  great  ob- 
jection ;  such  vesicles  result  not  unfrequently  from  contused  fi-actures 
with  extensive  rupture  of  the  deep  veins,  since,  from  obstruction  to 
the  flow  of  venous  blood,  the  serum  readily  escapes  from  the  cajjilla- 
ries,  and  elevates  the  hard  layer  of  the  epidermis  into  a  vesicle ;  we 
puncture  these  vesicles  with  a  needle,  gently  press  out  the  fluid,  and 
apply  some  wadding,  and  they  soon  dry  up.  It  is  the  same  with 
slight  superficial  excoriations  of  the  skin  ;  we  are  only  rarely  obliged 
to  remove  the  dressing  and  apply  another,  when  new  vesicles  form, 
as  we  may  know  by  the  pain. 

The  length  of  time  that  a  firm  dressing  must  remain  on  for  the 
difi'erent  fractures  you  will  learn  partly  in  the  clinic,  partly  from  spe- 
cial surgery  ;  I  simply  mention  here,  as  the  limits,  that  a  finger  may 
require  a  fortnight,  a  thigh  sixty  days,  or  more,  for  healing.  If  you 
apply  the  plaster-dressing  immediately  after  the  fracture,  dislocation 
having  been  completely  removed,  the  provisional  callus  wiU  always 
be  less,  and  hence  firmness  result  later,  than  where  there  is  some  dis- 
location and  the  dressing  is  applied  later ;  but  this  has  no  effect  on 
the  formation  of  definitive  callus,  and  the  actual  union  of  the  frac- 
tured ends  of  the  bone. 

[The  efficacy  of  plaster  bandages  depends  greatly  on  the  quality 
of  the  material  ;  we  may  easily  procure  good  modeling  plaster,  but 
it  spoils  if  kept  some  time,  without  being  entirely  protected  against 
air  and  moisture.  Now  in  tripolitli  we  have  a  material  possessing 
the  good  qualities  of  plaster,  without  its  disadvantages  ;  this  is  a 
grayish-black,  fine  powder  of  secret  composition,  to  be  used  just  as 
plaster  is,  but  having  the  following  advantages  :  1.  It  may  be  kept 
any  length  of  time,  even  in  an  open  vessel  ;  2.  It  is  lighter  than 
plaster,  hardens  even  more  rapidly,  and,  once  hardened,  resists  moist- 
ure ;  and,  3.  Is  cheaper  than  plaster.  It  is  used  in  just  the  same 
way  as  plaster,  which  it  will  probably  supplant. 

When  using  starch  bandages  we  may  employ  organtine,  or  lining- 
gauze,  which  is  coarse-meshed  and  starchy,  consequently  stiff  ;  when 
soaked  in  water  it  becomes  soft,  then  quickly  dries  and  hardens ; 


220  SIMPLE   FRACTURE   OF  BONES. 

several  layers  are  to  be  aiiplied,  and  they  unite  together  into  a  firm 
but  light  capsule.  This  simplifies  the  application  of  starch  band- 
ages, and  they  look  better, 

A  step  between  these  fixed  and  movable  dressings  is  the  gutta- 
percha splint  ;  for  this  we  use  sheet  gutta-percha,  cut  into  splints 
of  proper  size  ;  dip  these  in  very  hot  water  till  they  become  soft 
and  flexible,  then  apply  to  the  limb  after  smearing  it  with  oil,  and 
over  this  a  moist  bandage.  As  the  gutta-percha  cools  it  hardens. 
Sometimes  it  is  well  to  apply  a  firm  splint  till  the  other  is  perfectly 
hard.  The  advantages  of  this  splint  are  its  accurate  adjustment 
and  impermeability  to  water  ;  the  objection  is  its  cost,  although 
the  same  splint  may  be  used  several  times. 

In  some  parts  of  the  body  extension  and  counter-extension  by 
fixed  dressings  or  splints  are  very  difticult,  and  permanent  extension 
by  VolkinanrC s  method  is  resorted  to.  Two  long  pieces  of  adhe- 
sive plaster  two  inches  wide  are  applied  along  the  sides  of  the  limb 
and  kept  in  place  by  circular  turns,  a  roller  bandage  being  put  over 
the  whole  ;  a  piece  of  wood  is  placed  below  the  foot  like  a  stirrup, 
and  to  this  a  bag  of  sand  or  shot  is  attached  by  a  cord,  which  passes 
through  a  vertical  pulley  fastened  to  the  foot  of  the  bed.  The 
limb  is  placed  in  a  tin  trough,  running  by  means  of  small  rollers  on 
a  wooden  frame.  [This  is  a  slightly  complicated  BucJc's  apparatus.] 
The  weight  may  vary  from  four  to  ten  pounds,  according  to  the 
strength  of  the  patient  and  the  amount  of  dislocation.  This  weight 
is  divided  up  over  the  surface  of  the  limb,  and  is  well  borne.  Per- 
manent extension  may  be  resorted  to  for  fractures  of  the  humerus, 
but  is  not  often  used  in  such  cases,  unless  the  patient  is  kept  in  bed 
by  other  injuries. 

If  there  be  considerable  swelling,  with  crushing  and  sufi^usion 
of  the  skin,  and  formation  of  vesicles  full  of  bloody  serum,  before 
applying  a  fixed  dressing  certain  precautions  are  necessary.  Cir- 
cumscribed gangrene  of  the  skin  may  result,  changing  the  subcu- 
taneous into  an  open  fracture  ;  to  prevent  infection  and  decomposi- 
tion in  case  this  occurs,  after  cleansing  and  disinfecting  the  skin, 
the  crushed  part  should  be  covered  with  a  thick  layer  of  Lister's 
gauze  and  padding,  then  the  plaster  bandage  applied.  Under  this 
treatment  the  gangrenous  skin  dries  to  a  crust,  which  separates  with 
very  little  suppuration.  If  pain,  swelling,  and  fever  set  in,  the 
dressing  should  be  at  once  removed. 

We  may  here  discuss  an  important  question  :  Are  patients  fe- 
verish after  a  subcutaneous  fracture  ;  and,  if  so,  of  what  prognostic 
value  is  the  fever  ?  It  is  only  a  short  time  since  observations  have 
been  made  on  this  point.     When  the  patient  has  had  his  fracture 


TREATMENT  OF  FRACTURES.  221 

dressed,  he  usually  feels  comfortable  ;  so  it  was  taken  for  granted 
that  he  had  no  fever.  But  numerous  measurements  have  shown 
that  during  the  first  days  after  the  injury  the  evening  temperature 
is  often  102°  ;  though  this  is  almost  exclusively  in  cases  of  fracture 
of  the  long  bones,  and  when  there  is  great  extravasation  of  blood  ; 
but  even  Avhere  the  symptoms  of  this  complication  fail,  we  must 
suppose  that  there  is  a  certain  amount  of  extravasation  from  the 
ruptured  vessels  of  the  medulla,  and  this  must  be  reabsorbed.  In 
injuries  of  the  soft  parts  we  have  seen  that  reabsorj^tion  of  the 
primary  secretions  induced  fever,  hence  we  need  not  wonder  at 
finding  elevation  of  temperature  after  simple  fractures  ;  but,  as 
these  primary  secretions  are  not  very  irritant,  patients  are  not  par- 
ticularly uncomfortable,  and  the  temperature  subsides  after  four  or 
five  days  ;  if  it  recurs  in  the  second  or  third  week,  with  pain,  swell- 
ing, and  redness,  something  else  must  be  taking  place,  and  the 
dressings  should  be  removed,] 


CHAPTER   VI. 
OPEN  FEA  C TUBES  AXD  SUPP  URATION  OF  BONE. 

Difference  between  Subcutaneous  and  Open  Fractures  in  regard  to  Prognosis. — Vari- 
eties of  Cases. — Indications  for  Primary  Amputation. — Secondary  Amputation.— 
Course  of  tlie  Cure. — Suppuration  of  Bone. — Necrosis  of  the  Ends  of  Fragments. 

We  shall  noAV  pass  to  complicated  or  open  fractures. 

When  we  speak  simply  of  coynplicated  fractures,  we  usually 
mean  only  those  accompanied  by  wounds  of  the  skin.  Strictly  speak- 
ing, this  is  not  exact,  because  there  are  other  complications,  some  of 
them  much  more  important  than  wounds  of  the  skin.  If  the  skull  be 
fractured,  and  part  of  the  brain-substance  crushed,  or  some  ribs 
broken  and  the  lung  Avounded,  these  are  also  complicated  fractures, 
even  though  the  skin  should  remain  uninjured.  But,  since  in  these  cases 
the  complications  themselves  are  more  important  for  the  organism 
than  the  fractui-e  is,  we  usually  term  such  cases  contusion  of  the  brain, 
or  injury  of  the  lung,  with  fracture  of  the  skull  or  ribs.  But  we  shall 
not  here  enter  on  the  subject  of  injuries  of  internal  organs  by  frag- 
ments of  bone,  because  very  complicated  states  of  disease  are  occa- 
sionally induced  in  this  way,  whose  analysis  you  would  not  now  un- 
derstand. For  the  present  let  us  limit  ourselves  to  fractures  of  the 
extremities,  accompanied  by  wounds  of  the  skin,  which  we  shall  call 
open  fractures,  and  which  will  give  us  trouble  enough  in  their  course 
and  treatment. 

In  speaking  of  the  course  of  simple  contusions  without  wounds, 
and  of  contused  wounds,  I  have  already  shown  you  how  readily  reab- 
sorption  of  extravasated  blood  and  the  heahng  of  contused  parts  go 
on,  as  long  as  the  process  is  subcutaneous,  but  how  much  the  condi- 
tions change  if  the  skin  also  be  destroyed.  The  chief  dangers  in  such 
cases  are,  as  you  may  remember,  decomposition  in  the  wound,  exten- 
sive necrosis  of  crushed  or  dead  parts,  progressive  suppuration,  and 
accompanying  protracted,  exhausting  fever,  while   we  have  scarcely 


PROGNOSIS   IN   OPEN   FRACTURES.  223 

mentioned  the  severe  general  diseases,  erysipelas,  putrid-blood  \)o\- 
soning,  pyemia,  tetanus,  and  delirium  tremens.  The  difference  be- 
tween contusions  and  contused  wounds  is  even  more  strongly  marked 
in  simple  and  compound  fractures,  as  regards  course  and  prognosis. 
While  in  many  cases  we  can  scarcely  call  a  person  with  simple  frac- 
ture sick  (we  have  not  spoken  of  fever  there,  for  it  is  rarely  high), 
and  under  the  present  mode  of  treatment  such  an  injury  is  rather 
an  inconvenience  tlian  a  misfortune,  a  compound  fracture  of  a  large 
bone  of  an  extremity,  or  sometimes  even  of  a  finger,  may  induce 
severe,  and  too  frequently  fatal,  disease.  But,  not  to  alarm  you  too 
much,  I  will  at  once  add  that  there  are  many  grades  of  danger  even 
in  open  fractures,  and,  moreover,  that  their  treatment  has  been 
much  improved  of  late. 

It  is  very  desirable  and  important,  but  not  always  possible,  to  make 
a  correct  prognosis  about  an  open  fracture  at  once.  The  life  or  death 
of  the  patient  may  occasionally  hang  on  the  choice  of  the  treatment 
the  first  lew  days,  so  that  we  must  study  this  subject  more  accurately. 
The  symptoms  of  an  open  fracture  are  of  course  essentially  the  same 
as  of  the  subcutaneous,  except  that  discoloration  from  extravasated 
blood  is  often  wanting,  because  at  least  part  of  the  blood  escapes 
through  the  wound.  The  fractured  ends  not  infrequently  project  from 
tlie  wound,  or  lie  exposed  in  it,  so  that  a  glance  may  suffice  for  the 
diagnosis  of  an  open  fracture.  But  this  is  not  enough.  We  must  do 
our  best  to  ascertain  how  the  fracture  was  caused,  whether  by  direct 
01-  indirect  foi'ce,  and  how  great  the  force ;  if  it  was  accompanied  by 
crushing  and  twisting ;  whether  arteries  and  nerves  have  been  torn ; 
if  the  patient  lost  much  blood,  and  what  is  his  condition  at  present. 
There  aie  cases  where  we  can  say,  at  the  first  glance,  healing  is  im- 
possible ;  amputation  must  be  resorted  to.  W^hen  a  locomotive  has 
run  over  the  knee  of  an  unfortunate  railroad  hand,  when  a  hand  or 
forearm  has  been  caught  in  the  wheels  or  rollers  of  machinery,  Avhen 
a  premature  explosion  in  blasting  stone  has  crushed  or  torn  off  a  limb, 
or  hundred-weights  have  completely  mashed  a  foot  or  leg,  it  is  not 
"difficult  for  the  surgeon  to  decide  at  once  on  primary  amputation,  and 
usually  in  such  cases  the  state  of  the  limb  is  such  that  the  patients 
also,  though  with  a  sad  heart,  quickly  consent  to  the  operation.  These 
are  not  the  difficult  cases.  And  in  other  cases  it  may  be  just  as  easy 
to  foretell,  with  considerable  certaint}-,  the  probability  of  a  favorable 
cure.  For  instance,  if  fracture  of  the  leg  from  indirect  force  has  fol- 
lowed too  great  bending  of  the  bone,  the  broken  pointed  end  of  the 
crest  of  the  tibia  may  punctui'e  and  force  through  the  skin ;  in  such 
a  case  there  is  no  contusion,  but  simply  a  tear  through  the  skin. 
\Mien  a  pointed   body   strikes   forcibly  against  a  small  portion  of  a 


224  OPEN  FRACTURES  AND  SUPPURATION   OF  BONE. 

limb,  and  injures  bone  and  skin,  tlie  whole  extremity  may  be  greatly 
shaken ;  but  the  extent  of  the  injury  is  not  great,  and  most  of  such 
cases  terminate  favorably  under  suitable  treatment.  The  question- 
able cases  lie  between  these  two  extremes.  In  cases  where  there 
is  some  contusion,  but  only  a  slight  amount  evident,  and  the  skin  is 
only  injured  at  a  small  spot,  it  will  be  very  difficult  to  decide  whether 
healing  should  be  attempted  or  amputation  be  resorted  to,  and  the 
peculiarity  of  the  individual  case  alone  can  settle  the  question.  Of 
late  the  tendency  is  increasing  rather  to  try  to  preserve  the  limb  in 
these  doubtful  cases  than  to  amputate  one  that  might  possibly  have 
been  saved.  This  principle  is  certainly  justified  on  humane  grounds ; 
but  it  cannot  be  denied  that  this  conservative  surgery  may  be  prac- 
tised at  the  cost  of  life,  and  that  we  cannot  with  impunity  vary  too 
much  from  the  principles  of  the  older  surgeons,  who  generally  pre- 
ferred amputation  in  these  doubtful  cases.  Besides  mode  of  origin 
of  the  injiH-y,  and  the  amount  of  accomjDanying  contusion,  the  impor- 
tance in  any  given  case  depends  on  whether  we  have  to  deal  with 
deep  wounds,  with  fractured  bones  lying  far  down  among  the  muscles, 
or  with  bones  lying  near  the  skin,  as  the  danger  of  suppuration  de- 
pends greatly  on  the  depth  and  extent  of  the  bone-injury.  Thus,  an 
open  fracture  at  the  anterior  part  of  the  leg  is  of  more  favorable 
prognosis  than  a  similar  injury  of  the  arm  or  forearm.  Open  fractures 
of  the  thigh  are  the  most  unfavorable ;  indeed,  some  surgeons  always 
amputate  for  such  injuries.  Large  nerve-trunks  are  rarely  torn  in 
fractures,  and,  when  they  are,  it  does  not  seem  to  have  much  effect  on 
the  cure ;  and  experiments  on  animals,  as  well  as  observations  on 
man,  show  that  bones  may  unite  normally  in  paralyzed  limbs.  Injury 
of  large  venous  trunks,  as  of  the  femoral  vein,  causes  haemorrhage, 
which  may  be  readily  checked  by  a  compressing-bandage,  it  is  true, 
but  may  prove  dangerous  when  the  blood  effused  between  the  muscles 
and  under  the  skin  begins  to  decompose.  Rupture  of  the  arterial 
trunk  of  a  limb  occasionally  leads  at  once  to  considerable  arterial 
haemorrhages ;  but  this  is  not  a  necessary  sequence ;  for,  as  previously 
shown,  a  thrombus  quickly  forms  in  the  crushed  artery,  so  that  we  do 
not  always  have  extensive  hasmorrhage.  But,  if,  from  the  nature  of 
the  hfemorrhage,  we  recognize  the  rupture  of  an  artery,  according  to 
principles  already  laid  down,  we  should  either  attempt  to  ligate  the 
artery  at  the  wound,  or  else  at  the  point  of  election.  Rupture  of  the 
femoral  artery  with  fracture  of  the  femur  is  found  by  experience  to 
be  followed  by  gangrene,  and  is  an  imperative  indication  for  ampu- 
tation ;  in  a  corresponding  injury  of  the  arm,  recovery  may  result 
or  gangrene  may  follow.  In  fractures  of  the  forearm  or  leg,  even  if 
one  or  both  arteries  be  ruptured,  recovery  may  take  place.     Lastly, 


PROGNOSIS  IN  OPEN  FRACTURES.  225 

111  the  question  as  to  whether  we  shall  try  for  union,  or  proceed  to 
amputation,  we  must  consider  how  useful  the  limb  can  be  if  union 
results  and  all  unfavorable  chances  have  been  overcome.  In  compli- 
cated fractures  of  the  foot  and  lower  part  of  the  leg  this  question 
may  be  particularly  important,  and  it  has  frequently  been  necessary 
to  amputate  a  foot  because  of  the  change  of  form  and  position  result- 
ing after  union  of  an  open,  comminuted  fracture,  which  rendered  it 
useless  for  walking.  The  same  thing  is  to  be  considered  when,  in  a 
case  of  moderately  extensive  gangrene  of  the  foot,  we  wish  to  decide 
if  it  should  be  amputated  or  not.  The  dead  portion  of  the  foot  may 
be  detached  in  such  an  inconvenient  shape  that  the  remaining  stump 
is  neither  useful  for  walking  nor  for  the  adaptation  of  an  artificial 
hmb.  In  such  cases  we  should  amputate,  for  all  our  methods  of  am- 
putating are  designed  for  the  future  application  of  artificial  limbs. 

Since  the  nature  of  the  subject  has  led  us  directly  to  the  indica- 
tions for  amputation  in  injuries,  I  shall  at  once  proceed  to  the  sul> 
ject  of  secondary  amputaUo7is.  In  the  question  as  to  whether  a 
complicated  fracture  should  be  amputated  or  not,  you  might  readily 
satisfy  yourself  with  the  idea  that  it  might  be  done  at  any  future 
time  if  the  fears  of  an  unfavorable  course  should  be  realized.  On  this 
point  attentive  observation  shows  that  there  are  two  periods  for  this 
secondary  amputation.  The  first  danger  threatens  the  patient  from 
an  acute  decomposition  about  the  wound  and  the  consequent  putrid 
intoxication  of  the  blood.  The  question  as  to  this  danger  is  settled 
during  the  first  four  days;  if  it  arises,  and  you  then  amputate  (this 
must  be  done  far  above  the  point  of  putrefaction),  it  is  just  at  the  most 
unfavorable  period  for  the  operation,  for  you  will  very  rarely  succeed 
in  saving  your  patient.  Somewhat  more  favorable,  but  still  unfavor- 
able as  compared  with  primary  amputations  (those  made  within  the 
first  forty-eight  hours),  are  the  results  of  amputations  made  from  the 
eighth  to  the  fourteenth  day ;  they  are  particularly  unfavorable  if  the 
symptoms  of  acute  jxirulent  infection,  pyremia,  are  distinctly  present. 
If  the  patient  has  survived  two  or  three  weeks,  and  profuse  exhaust- 
ing suppuration  or  other  local  indication  for  amputation  arise,  the 
results  are  again  relatively  favorable.  When  some  surgeons  have 
asserted  that  secondary  amputations  give  better  results  than  primary, 
they  have  almost  exclusively  considered  these  later  secondary  ampu- 
tations. But,  if  we  bear  in  mind  how  many  patients  with  open  frac- 
tures die  during  the  first  three  weeks,  that  is,  how  few  of  them  live  till 
the  favorable  time  for  secondary  amputations,  it  seems  to  me  we  can 
have  no  doubt  about  the  decided  advantages  of  primary  amputations. 
Up  to  the  present  time  I  have  rarely  found  indications  for  late  second- 
ary amputations. 
18 


226      OPEN  FRACTURES  AND  SUPPURATION  OF  BONE. 

An  open  fracture  may  unite  in  various  ways.  The  skin-wound,  as 
well  as  the  deeper  parts,  occasionally  heals  by  first  intention ;  this  is  the 
most  favorable  case.  Under  modern  treatment  this  occurs  more  fre- 
quently than  formerly,  although,  from  the  nature  of  the  case,  the  re- 
quirements for  this  result  are  not  often  present.  Far  more  frequently 
(and  this  is  also  favorable)  the  wound  only  suppurates  superficially, 
and  not  between  and  around  the  ends  of  the  bone,  but  union  of  the 
bone  takes  place  as  in  simple  subcutaneous  fi-acture.  The  cases  where 
the  wound  only  affects  the  skin,  and  does  not  communicate  with  the 
fracture,  should  not  be  counted  among  complicated  fractures ;  but  tlie 
limits  are  difficult  to  trace. 

The  process  of  cure  must  of  course  diflFer  greatly  from  the  above, 
if  the  skin-wound  be  large,  the  soft  parts  greatly  contused,  so  that 
fragments  are  detached  from  them ;  if  the  sujipuration  extends  deep 
between  the  muscles  and  around  the  bone,  and  even  into  its  medullary 
cavity ;  if  the  fragments  are  bathed  in  pus ;  if  half-loose  pieces  of 
bone  lie  about,  and  longitudinal  fissures  extend  into  the  bone.  The 
activity  of  the  soft  parts  will  remain  essentially  the  same  as  in  subcu- 
taneous fractures,  except  that  in  this  case  the  inflammatory  new  forma- 
tion does  not  directly  become  callus,  but,  after  detachment  of  the 
crushed,  necrosed  shreds  of  tissue,  granulations  and  pus  are  formed, 
the  former  of  which  are  transformed  to  ossifying  callus.  The  form  of 
the  callus  Avill  not  be  much  changed,  except  that,  where  the  open 
suppurating  wound  exists  for  a  long  time,  there  will  be  a  gap  in  the 
callus-ring  till  it  is  closed  by  the  after-growth  of  deep  ossifying  granu- 
lations. Hence  the  process  will  terminate  far  more  slowly  than  in 
subcutaneous  fracture,  just  as  healing  by  suppuration  takes  longer 
than  healing  by  first  intention. 

Now,  what  becomes  of  the  ends  of  the  fragments  which,  partly  or 
entirely  denuded  of  periosteum,  lie  in  the  wound  ?  What  becomes 
of  pieces  detached  from  the  bone,  and  only  loosely  attached  to  the  soft 
parts  ?  As  in  the  soft  parts,  so  here  one  of  two  things  may  happen, 
according  as  the  ends  of  the  bone  are  living  or  dead.  In  the  first  and 
most  frequent  case,  granulations  grow  directly  from  the  surface  of  the 
bone.  In  the  latter,  as  in  the  soft  parts,  plastic  activity  in  the  bone 
occurs  on  the  borders  of  the  living ;  interstitial  granulations  and  pus 
form  ;  the  bone  melts  away  ;  the  dead  end  of  the  bone,  the  seqxiestmm^ 
falls  off.  The  extent  to  which  this  process  of  detachment  goes  natu- 
rally depends  on  the  extent  to  which  the  bone  is  dead,  or,  expressed 
more  physiologically,  on  the  extent  to  which  the  circulation  has  ceased 
from  stoppage  of  the  vessels.  This  extent  may  vary  greatly  :  it  may 
possibly  extend  only  to  the  superficial  layer  of  tlie  injured  bone :  and, 
since  the  whole  process  is  called  necrosis^  this  superfici?l  detachment 


UNION  OF  OPEN  FRACTURES.  227 

of  a  plate  of  bone  is  termed  necrosis  superJiciaUs^  while  that  of  the 
whole  fractured  end  of  the  bone  may  be  called  necrosis  totalis  y  but 
tlie  latter  term  is  more  usual  for  indicating  that  the  entire  diaphysis 
of  a  long  bone,  or  at  least  the  greater  part  of  it,  is  detached,  and  the 
opposite  of  this  is  7iecrosis  2)artialis.  The  opposite  of  the  above- 
mentioned  necrosis  superficialis,  which  is  also  termed  exfoliation,  is 
properly  necrosis  centralis,  that  is,  detachment  of  an  inner  portion  of 
bone.  Necrosis  superficiaHs  and  necrosis  of  the  broken  ends  and 
partly-detached  fragments  of  the  bone  are  so  often  combined  with  sup- 
purating fractures,  of  which  we  have  to  treat  here,  that  we  must  treat 
of  them  in  this  place.  It  will  at  first  seem  strange  to  you  that  vascu- 
lar granulations  should  spring  from  the  hard,  smooth  cortical  substance 
of  a  long  bone.  From  what  has  already  been  said,  it  will  seem  pos- 
sible that,  under  the  influence  of  this  plastic  process,  the  hard  osseous 
tissue  should  be  so  dissolved  that  there  may  be  a  spontaneous  solu- 
tion of  continuity  between  the  dead  and  healthy  bone.  We  shall  now 
study  more  exactly  these  processes  of  formation  of  granulations  and 
of  suppuration  in  bone. 

You  will  remember,  from  the  full  description  of  traumatic  suppu- 
ration of  the  soft  parts,  that  in  traumatic  inflammation  the  process 
chiefly  depends  on  free  suppuration  and  extensive  formation  of  new 
vessels,  as  well  as  on  direct  cell-infiltration  from  the  blood,  while  the 
intercellular  substance  assumes  a  gelatinous  or  fluid  consistence. 
Both  of  these  processes  can  only  take  place  to  a  slight  extent  in  bone, 
especially  in  the  firm  cortical  substance  of  a  long  bone,  because  the 
rirm  osseous  substance  prevents  much  dilatation  of  the  capillaries 
which  are  enclosed  in  the  Haversian  canals.  I  may  at  once  call  your 
attention  to  the  fact  that,  from  this  slight  distensibility  of  the  vessels 
in  the  osseous  canals,  portions  of  bone  may  more  readily  die  than 
would  be  the  case  with  the  soft  parts,  because,  in  case  of  coagulation 
of  blood,  even  in  the  smaller  vessels,  the  nutrition  can  be  only  imper- 
fectly kept  up  by  collateral  circulation.  Moreover,  the  connective 
tissue  and  the  vessels  in  the  Haversian  canals  may  be  entirely  de- 
stroyed by  suppuration,  so  that  necrosis  at  the  ends  of  the  fragments 
will  be  inevitable.  Should  a  vascular  granulation-tissue  develop  on 
the  surface  of  the  bone  or  in  its  compact  substance,  this  can  only  occur 
as  previously  described,  after  the  osseous  substance  (lime-salts  as  well 
as  organic  matter)  has  disappeared  at  the  point  where  the  new  tissue 
is  to  appear ;  hence  there  must  be  solution  and  atrophy  of  the  bone- 
tissue,  just  as  there  are  of  the  soft  parts  under  similar  circumstances 
(see  Fig.  39).  The  whole  difference  appears  cliiefly  in  the  difference 
of  time,  for  the  development  of  granulations  on  and  in  the  bone  takes 
much  longer  than  in  the  soft  parts.     I  have  already  stated  that  the 


228  OPEN  FRACTURES  AND  "SUPPURATION   OF  BONE. 

same  i^rocess  requires  much  longer  in  the  tendons  and  fascia,  which 
have  few  vessels,  than  in  the  connective  tissue,  muscles,  and  skin  ;  in 
the  bone  it  requires  even  more  time  than  in  the  tendons.  The  con- 
stitutional power  of  the  individual,  and  the  consequent  so-callod 
vitality  of  the  tissues,  are  also  to  be  taken  into  consideration. 


LECTURE   XVI. 

Development  of  Osseous  Granulations. — Histology. — Detachment  of  the  Sequestrum.— 
Histology. — Osseous  New  Formation  around  the  Detached  Sequestrum. — Callus  in 
Suppurating  Fractures. — Suppurative  Periostitis  and  Osteomyelitis, — General  Con- 
dition.— Fever.— Treatment ;  Fenestrated,  Closed,  Split  Dressings, — Antiphlogistic 
Remedies. — Immersion. — Rules  about  Bone-spliuters. — After-Treatment. 

When  a  denuded  portion  of  bone  begins  to  throw  out  granula- 
tions on  its  surface  (which  in  complicated  fractvires  we  can  only  see 
when  the  ends  of  the  fragments  are  exposed  by  a  large  skin-wound, 
on  the  interior  surface  of  the  leg,  for  instance),  we  recognize  this  with 
the  naked  eye  by  the  following  changes :  For  the  first  eight  or  ten 
days  after  being  denuded  of  periosteum,  the  bone  mostly  preserves  its 
pure  yellowish  color,  which,  even  during  the  last  day  of  the  above 
period,  changes  toward  bright  rose-color.  If  we  then  examine  the 
surface  of  the  bone  with  a  lens,  we  may  notice  numbers  of  very  fine 
red  points  and  striae,  which  a  few  days  later  become  visible  to  the 
naked  eye  also ;  these  rapidly  increase  in  size,  grow  in  length  and 
breadth,  till  they  unite  and  then  present  a  perfect  granulating  surface 
which  passes  immediately  into  the  granulations  of  the  surrounding 
soft  parts,  and  subsequently  participates  in  the  cicatrization,  so  that 
such  a  cicatrix  adheres  firmly  to  the  bone. 

If  we  follow  this  process  in  its  finer  histological  details,  which 
must  be  chiefly  done  experimentally,  by  aid  of  injected  bones  de- 
prived of  their  litne,  we  have  the  following  result :  If  the  circulation 
in  the  bone  is  maintained  near  to  the  surface,  there  is  a  rich  infiltra- 
tion of  cells  into  the  connective  tissue  accompanying  the  vessels  in 
the  Haversian  canals ;  this  tissue  grows,  with  the  vascular  loops  de- 
veloping toward  the  siorface,  out  of  the  bone  at  the  points  where  the 
Haversian  canals  open  externally.  The  development  of  this  young 
granulation-mass  laterally  results  at  the  expense  of  reabsorbed  bone. 
If  we  macerate  one  of  these  bones  with  superficial  granulations,  its 
surface  will  appear  gnawed  and  rough ;  in  the  living  bone,  gTanulation 
tissue  fills  the  numerous  small  holes,  which  all  communicate  with  the 
Haversian  canals.     The  surface  of  the  bone  does  not,  however,  remain 


I 


UNION   OF   OPEN  FRACTURES. 


229 


in  this  state,  but,  while  the  osseous  granulations  on  the  surface  con- 
dense to  connective  tissue  and  cicatrize,  in  the  deeper  parts  thej^ 
ossify  quite  rapidly,  so  that  at  the  termination  of  the  process  of  heal- 
ing  the  surface  of  the  injured  bone  does  not  show  a  deficiency,  but 
appears  denser  from  deposit  of  new  bone.  You  see  that  here  too  the 
circumstances  are  exactly  the  same  as  in  subcutaneous  development  of 
the  inflammatory  neoplasia.  If  you  look  at  Fig.  49,  and  suppose  the 
periosteum  removed  from  the  surface  of  the  bone,  the  new  formation 
(in  this  case  as  granulations)  will  grow  fungous-like  out  of  the  Haver- 
sian canals. 

You  will  understand  this  better  if  we  now  follow  more  carefully 
the  process  of  detachment  of  necrosed  portions  of  bone.  Let  us  re- 
turn to  what  we  see  with  the  naked  eye,  and  let  us  suppose  we  have 
before  us  a  portion  of  the  parietal  bone  denuded  of  soft  parts ;  then, 
if  no  granulations,  as  above  described,  grow  from  the  bone,  we  shall 
have  the  following  symptoms :  While  the  svu-rounding  soft  parts  and 
the  portion  of  bone  still  covered  with  periosteum  have  already  pro- 
duced numerous  granulations  and  secrete  pus,  the  dead  portion  of 
bone  remains  pure  white  or  becomes  gray  or  even  blackish.  It  re- 
mains some  weeks,  sometimes  two  months  or  more;  most  proliferani 
granulations  grow  around  it ;  cicatrization  has  already  begun  in  the 
periphery  of  the  wound,  and  we  cannot  decide  how  the  case  will  ter- 
minate, for  in  the  sixth  week  the  surface  of  the  bone  may  look  just  as 
it  did  the  day  after  injury.     Some  day  we  feel  the  bone  and  find  it 


Detachment  of  a  superficial  piece  of  a  flat  bone  (as  of  one  of  the  cranial  bones),  which  has  been  ex- 
posed by  an  injury  and  become  necrosed.  Necrosis  superflcialis ;  a,  the  sranulations  arisinfr  from 
the  living  portion  of  the  bone  undermine  the  dead  portion,  the  sequestrum  (shaded  vertically) ; 
&,  the  lower  side  of  the  sequestrum  has  been  considerably  eaten  away  by  the  granulations,  which 
have  perforated  it  at  various  points.     Diagram,  natural  size. 


230 


OPEN   FRACTURES  AND   SUPPURATION   OF   BONE. 


movable ;  after  a  few  attempts  one  blade  of  the  forceps  may  be  intro- 
duced under  it  and  we  lift  off  a  thin  plate  of  bone,  under  which  we 
find  luxuriant  granulations  ;  the  under  surface  of  this  plate  is  very 
rough,  as  if  eaten  away.  Now  healing  goes  on  rapidly.  It  is  often 
long  before  the  cicatrix  becomes  permanent  and  solid  enough  to  re- 
sist all  injuries,  such  as  pressure  and  friction,  but  healing  often  termi- 
nates favorably.  This  is  the  process  that  we  term  necrosis  superfi- 
cialis  or  exfoliation  of  bone.  We  are  already  acquainted  with  this 
process  in  the  soft  parts ;  during  the  first  week  large  shreds  of  tissue 
fall  from  the  contused  wound,  since  on  the  border  of  the  healthy  tis- 
sue there  is  an  interstitial  development  of  granulation,  by  which  the 
tissue  is  detached ;  the  process  is  the  same  here.  In  a  bone  deprived 
of  its  lime  we  may  readily  examine  these  processes  anatomically.  The 
inflammatory  neoplasia,  or  granulation  tissue,  develops  on  the  mar- 
gin of  the  healthy  bone  in  the  Haversian  canals.  The  accompanying 
figure  (Fig.  55)  may  represent  to  you  the  details  of  this  process. 

If  you  have  fully  understood  what  has  been  said,  it  only  requires 
a  slight  stretch  of  imagination  to  see  how  the  same  process  of  detach- 
ment of  a  fragment  may  extend  through  the  entire  thickness  of  bone ; 
that  is,  how  (and  here  we  come  back  to  complicated  fractures)  a  vari- 
able length  of  the  fractured  end  of  a  bone  may  be  entirely  detached, 
when  it  is  incapable  of  hving. 
When  the  bone  in  question  is 
thick,  this  process  requires  sev- 
eral months;  but  at  last  we 
may  find  even  large  pieces  of 
bone  movable  in  the  wound,  and 
remove  them  as  we  would  a  su- 
perficial bony  plate. 

As  regards  splinters  entirely 
detached  from  the  bone,  and  only 
attached  to  the  soft  parts,  their 
future  fate,  as  regards  living  or 
not,  depends  on  how  far  their 
circulation  is  preserved.  If  they 
are  not  capable  of  living,  they 
at  last  become  entirely  detach- 
ed by  suppuration  of  the  soft 
parts  attached  to  them,  and  of- 
ten, as  foreign  bodies,  keep  up  Diagram  of  detachment  of  a  necrosed  portion  of 
.     -,    ,.  i»  ,.  »   ,1  bone.    MasTiifiud  3tK).    a,  necrosed  portion  of 

irritation  and  suppuration  OI   the       bone;  Mivins  bone;  c,  new  formation  in  the 
1        Tf  4-V,  1,1         e       Haversian  canals,  by  which  the  bone  ia  de- 

WOUnd.      It   they   are   capable   of       tached.    Compare  Fig.  36. 

living,    they    produce    granula- 


DETACHMENT   OF  THE   SEQUESTRUM. 


231 


lions  on  the  free  surface ;  tlaese  subsequently  ossify  and  unite  with  the 
other  callus,  forming  around  the  fractured  ends. 

To  represent  the  relation  of  the  formation  of  callus  to  this  process 
of  detachment  of  the  necrosed  ends  of  the  fractured  bone,  I  present 
the  following  figure  (Fig.  56). 

The  fragments  of  the  broken  bone  are  not  accurately  adjusted^ 
but  displaced  somewhat  laterally ;  the  ends  of  the  fragments  have 
both  become  necrosed,  and  nearly  detached  by  interstitial  proliferation 
of  granulations  on  the  borders  of  the  living  bone.  The  whole  wound 
is  lined  with  granulations,  which  secrete  pus  that  escapes  at  d.  In 
both  fragments,  an  inner  callus  (5  V)  has  formed,  which,  however,  from 
suppuration  of  the  fractured  surfaces,  has  not  yet  been  soldered  to- 
gether. The  outer  callus  (c  c)  is  irregular,  and  interrupted  at  c?,  be- 
cause the  pus  escapes  here  from  the  first.  When  the  granulations 
grow  so  strongly  as  to  fill  the  entire  cavity,  and  subsequently  ossify, 
healing  is  completed,  and  the  final  result  is  just  the  same  as  in  the 
healing  of  subcutaneous  fractures.  For  this  to  take  place  the  necrosed 
portions  of  bone  must  be  removed,  for  experience  shows  they  cannot 
Ileal  up  in  the  osseous  cicatrix.     This  elimination  of  the  sequestrated 


Fio.  66. 


Fig.  5 


c  1 


diagram  of  fracture  of  a  long  bone  with 
external  wound,  longitudinal  section. 
Natural  size,  ee,  bone;  /y//,  soft  parts 
of  the  limb ;  aaa  a,  necrosed  ends  of 
bone.  The  darkly-shaded  part  repre- 
sents the  granulations,  which  line  (cT) 
the  wound  that  opens  outwardly,  and 
secrete  pus;  S5,  internal  callus  in  the 
two  dislocated  ends  of  bone;  cc  exter 
nal  callus. 


Amputation  stump  of 
the  thigh,  with  necro- 
sis of  the  sawed  sur- 
face. 


232      OPEN  FRACTURES  AND  SUPPURATION  OF  BONE. 

fragments  takes  place  either  by  reabsorption  or  by  artificial  removal 
outwardly ;  the  former  is  the  more  frequent  in  small,  the  latter  in 
large  sequestra;  but  union  will  not  result  as  long  as  the  sequestrum 
remains  .between  the  granulations  of  the  fragments.  Since  the  open- 
ing at  d  may  be  much  contracted  by  the  development  of  external 
callus,  the  operative  removal  of  the  necrosed  ends  is  often  very  diffi- 
cult. We  find,  by  examination  with  the  probe,  whether  such  seques- 
tra in  the  deeper  parts  really  existed,  and  if  they  are  detached.  If 
you  suppose  the  sequestrum,  a  a  (Fig.  56),  removed  from  the  wound, 
there  is  no  obstacle  to  the  filling  of  the  wound  with  granulations  and 
to  their  subsequent  ossification.  Such  sequestra  in  complicated  frac- 
tures are  frequently  the  cause,  not  only  of  new  exacerbations  of  the 
acute  suppurative  inflammation,  but  also  of  subacute  and  chronic  peri- 
ostitis, with  protracted  firm  oedema  of  the  extremity  and  annoying 
eczematous  eruptions  on  the  skin,  as  well  as  of  long-continued  bone 
fistulce  and  ulcerations  of  the  ends  of  the  fragment.  The  action  of 
this  sequestrum  combines  the  double  effect  of  a  foreign  body  and 
that  of  local  or  general  purulent  infection. 

We  may  speak  here  of  conditions  as  they  exist  in  the  bone  after 
amputation.  Imagine  Fig.  56  divided  transversely  at  the  point  of 
fracture  and  the  lower  half  removed,  then  the  condition  will  be  just 
the  same  as  after  amputation.  Granulations  either  grow  directly 
from  the  wounded  surface,  or  a  portion  (the  sawed  surface)  is  necrosed 
to  a  greater  or  less  extent  (Fig.  57).  Let  this  be  as  it  may,  in  the 
medullary  cavity,  as  well  as  on  the  outside  of  the  bone,  a  neoplasia 
(a  half  callus)  is  formed;  this  subsequently  ossifies;  if  you  examine  an 
amputation  stump  several  months  old,  you  wiU  find  the  medullary 
space  in  the  stump  of  the  bone  closed  by  osseous  deposits,  as  well  as 
external  thickening  of  the  bone.  We  may  here  remark  that  the  name 
callus  is  used  almost  exclusively  for  the  bony  new  formation  in  frac- 
tures, while  the  young  bony  formations  on  the  outside  occurring  in 
various  ways  are  called  "  osteophytes  "  (from  bartov^  bone,  and  ^vfia^ 
tumor)  ;  callus  and  osteophytes  are  not  then  very  different,  but  both 
are  designations  for  young  osseous  formations. 


In  considering  the  process  of  suppuration,  we  have  left  out  of  con- 
sideration two  of  the  constituents  of  bone,  namely,  the  periosteum  and 
medulla.  In  obser\ang  the  development  of  callus,  Ave  saw  that  the 
periosteum  also  had  something  to  do  with  the  formation  of  new  bone. 
But,  if,  in  open  suppurating  fractures,  the  suppurative  inflammation 
spreads  greatly  as  a  result  of  extensive  contusion,  a  large  amount  of 


SUPPURATIVE  PERIOSTITIS.  233 

periosteum  may  necrose  or  suppurate,  and  in  such  cases  Are  find 
wide-spread  suppurative  periostitis  y  the  greater  part  of  a  long  bone, 
as  the  tibia,  may  be  bathed  in  pus.  The  bone  thus  losing  its  connec- 
tion with  the  soft  parts,  its  supply  of  blood  is  wdthdrawn,  and  from 
this  cause  there  may  be  extensive  necrosis  of  the  bone  as  a  result  of 
suppiu-ative  periostitis.  But  these  local  dangers  are  slight  in  com- 
parison to  the  dangers  to  the  organism  at  large  from  these  deep  sup- 
purations ;  we  shall  hereafter  treat  fully  of  these. 

In  the  same  way  the  medulla  either  of  a  long  or  spongy  bone  may 
participate  in  the  suppuration.  From  what  has  already  been  said,  you 
know  that,  in  the  course  of  the  normal  union  of  fracture,  new  bone- 
tissue  forms  in  the  medullary  cavity,  and  closes  it  for  some  time.  In 
open,  suppurating  fractures  there  is  also  occasionally  suppuration  of 
the  medulla,  that  may  extend  more  or  less.  Such  a  suppurative  os- 
teom3-elitis  is  quite  as  dangerous,  both  for  the  hfe  of  the  bone  and  for 
the  entire  organism,  as  suppurative  periostitis.  From  various  causes, 
Coo,  it  may  asssume  a  putrid  character ;  the  larger  veins  of  the  bone, 
that  come  from  the  medulla,  may  participate  in  the  suppuration,  and 
this  disease  is  the  more  destructive  because  of  its  deep  situation ;  it  is 
often  first  recognized  at  the  autopsy.  Purulent  osteomyelitis  alone 
may  also  lead  to  partial  and  even  to  total  necrosis  of  a  bone,  the  more 
so  when  combined  with  suppurative  periostitis. 

Although  it  was  necessary  to  make  you  acquainted  with  all  the 
above  local  complications  of  open  fractures,  I  may  say  for  your  relief 
that  they  rarely  occur  so  extensively  as  above  described ;  neither  total 
necrosis  of  both  ends  of  the  fracture,  nor  extensive  purulent  perios- 
titis and  osteomyelitis  are  frequent  results  of  these  fractures ;  but,  for- 
tunately, healing  of  the  deeper  parts  often  takes  place  very  simply, 
and  suppuration  only  continues  externally. 

Fracture  does  not  always  result  from  the  action  of  a  strong  di- 
rect force  on  a  bone  ;  the  injury  may  vary  from  contusion  of  the 
periosteum  to  crushing  of  the  bone.  There  may  have  been  merely 
compression  of  the  periosteum,  or  the  force  may  have  bent  the 
bone,  which  sprang  back  to  its  normal  shape  without  breaking  ;  but 
at  the  same  time  the  medulla  may  have  been  greatly  crushed.  In 
the  spongy  substance  there  may  be  slight  breaks  or  bends,  which 
are  never  entirely  dissipated,  even  though  the  cortical  substance 
has  not  perceptibly  changed  its  form.  All  these  injuries  of  bones 
resulting  from  strong  compression  are  classed  as  contusions  of  bone. 
Concussion  of  bone  may  result  from  either  direct  or  indirect  force, 
and  be  marked  by  ruptures  of  the  medulla  and  haemorrhages. 
After  these  injuries,  pains  and  disturbance  of  function  are  greater 
than  after  injuries  of  the  soft  parts  ;  a  certain  diagnosis  of  the 


234  OPEN   FRACTURES  AND   SUPPURATION   OF  BONE. 

grade  is  often  impossible  at  first.  Occasionally  concussions  of  bone 
with  contusion  (as  in  falls  on  the  great  trochanter)  result  in  long- 
continued  ostitis,  which  is  not  often  accomi^anied  by  suppuration, 
but  by  formation  of  osteoj^hytes,  sclerosis,  and  protracted  impair- 
ment of  function,  which  in  old  persons  may  prove  permanent. 

Whether  a  traumatic  inflammation  leading  to  suj^puration  shall 
extend  beyond  the  borders  of  the  irritation  (of  the  injury)  depends, 
as  in  simple  contused  wounds,  on  the  grade  of  the  local  infection  by 
mortifying  tissue  in  the  wound,  and  later  on  all  the  circumstances 
that  we  have  learned  as  direct  or  indirect  causes  of  secondary  in- 
flammation of  wounds. 

[The  injury  to  the  soft  parts  at  the  time  of  the  fracture  has  a 
great  effect  on  the  cure  ;  for  experience  shows  that  extensive  inju- 
ries to  bones,  as  in  gunshot  injuries,  are  very  dangerous,  not  so 
much  on  account  of  the  fractures  as  from  coincident  tearing  and 
crushing  of  the  parts  around  the  bone.  On  the  other  hand,  in  os- 
teotomies of  the  long  bones  you  may  separate  a  piece  by  the  chisel 
and  injure  the  medulla  so  that  fat-drops  will  stream  out  with  the 
blood,  and  nevertheless  the  wounded  bone  may  heal  without  forma- 
tion of  a  drop  of  pus,  if  the  soft  parts  have  not  been  injured  or  the 
wound  been  infected.  This  would  show  that  for  the  bone,  as  well 
as  the  soft  parts,  it  is  not  so  much  the  injury  as  the  complications 
that  cause  inflammation  and  suppuration.  Bone  really  offers  the 
most  favorable  conditions  for  healing  by  granulation  without  reac- 
tion. It  is  not  strange  that  inflammation  and  suppuration  occur  in 
many  cases  of  complicated  fracture  not  treated  antiseptically  :  they 
may  be  rendered  unclean  by  foreign  bodies  at  the  time  of  injury  ; 
moreover,  the  soft  parts  are  bruised,  and  between  the  ends  of  the 
bone  and  all  around  lie  blood  and  tissue-fluids,  which  are  mixed 
with  air  at  the  time  of  injury  and  by  movements  of  the  parts,  thus 
receiving  more  ferments.  If  we  take  the  most  favorable  cases, 
where  the  soft  parts  and  bone  are  capable  of  living  and  must  not 
necessarily  mortify,  decomposition  of  the  extravasations  can  hardly 
be  prevented  ;  fluid  containing  cocci  collects  in  the  wound  and 
smells  bad,  even  the  day  after  the  injury.  The  more  diflicult  the 
escape  of  the  secretions  through  the  wound  in  the  soft  parts,  the 
more  the  tissue  is  crushed  and  the  circulation  disturbed,  the  more 
quickly  will  decomposition  extend  to  the  whole  wound  ;  the  decom- 
posing matter  will  be  absorbed  and  induce  general  septic  infection, 
and  wherever  it  infiltrates  the  tissues  an  intense  inflammation  arises, 
first  in  the  soft  parts,  but  subsequently  in  the  medulla  and  perios- 
teum. If  the  escape  of  secretion  be  impeded,  as  when  thick  layers 
of  muscles  cover  the  bone,  and  the  wounds  of  the  different  layers 


TREATMENT   OF   COMPLICATED   FRACTURES.  235 

do  not  exactly  correspond,  the  decomposing  secretion  may  be  so 
compressed  between  the  ends  of  the  f ractui-ed  bone  as  to  be  actu- 
ally pressed  into  the  medulla,  and  induce  progressive  osteomyelitis. 
Thus  we  see  how  important  are  the  injuries  to  the  soft  parts  in 
complicated  fractures,  and  how  much  subsequent  symptoms  depend 
on  the  repair  of  the  surrounding  tissues  ;  and  that  the  amount  of 
injury  done  to  them  greatly  affects  the  prognosis.  The  j^rognosis 
also  depends  greatly  on  how  soon  after  the  injury  the  case  comes 
under  treatment :  in  the  one  case  the  aim  of  treatment  would  be  to 
avoid  infection,  in  another  to  arrest  or  modify  a  process  of  decom- 
position already  begun.  In  this  respect  complicated  fractures  are 
like  contused  wounds,  but  the  conditions  are  more  unfavorable  ; 
the  more  the  complication  approximates  an  incised  wound  the  better 
the  prognosis. 

Where  the  force  applied  has  been  very  great,  death  may  result 
in  a  few  hours  from  shock  or  from  rapid  septic  poisoning  ;  the  case 
is  about  the  same  as  after  contused  wounds.  Even  when  a  limb  is 
amputated  at  once,  the  patient  may  die  in  a  few  hours  ;  if  he  lives 
twenty-four  to  forty-eight  hours,  it  may  be  difficult  to  say  whether 
he  dies  from  shock,  or  acute  septicaemia,  or  from  both.  Decompo- 
sition may  be  so  rapid  that  a  quantity  of  poison  passes  at  once  into 
the  lymph  and  blood-vessels  and  induces  sudden  intoxication — so 
sudden  that  its  symptoms  hardly  have  time  to  develop. 

Another  complication  that  may  prove  fatal,  either  in  complicated 
or  simple  fractures,  is  fat-embolism  of  the  blood-vessels.  For  fat- 
molecules  to  enter  the  circulation,  there  must  at  some  point  be  free 
fat  (i.  e.,  fat  not  enclosed  in  cells),  and  injured  vessels  through 
whose  openings  drops  of  fat  may  pass  and  be  conveyed  along  by 
the  blood.  These  conditions  are  present  in  any  fracture,  but  par- 
ticularly where  the  medulla  has  been  extensively  crushed  and  its 
vessels  torn.  As  fat-drops  entering  the  circulation  are  carried  cen- 
tripetally,  they  reach  the  i-ight  heart,  thence  pass  to  the  lungs, 
where  they  are  caught  in  the  capillaries  of  the  alveoli,  as  may  be 
seen  with  the  microscope  ;  they  act  as  mechanical  emboli,  no  change 
taking  place  in  their  vicinity.  Harmless  as  limited  embolism  of 
this  sort  may  be,  and  often  as  it  probably  occurs  without  reaction, 
it  is  very  dangerous  when  it  takes  place,  not  only  in  numerous  capil- 
laries of  the  lungs,  but  in  the  brain,  heart,  intestines,  liver,  kidneys, 
etc.  ;  in  such  cases  the  fatty  embolism  may  be  the  sole  and  imme- 
diate cause  of  death,  as  is  shown  by  many  published  cases.  Under 
these  circumstances  death  may  result  in  a  few  days  after  the  injury  ; 
but  this  unfortunate  termination  is  rare,  and  the  diagnosis  should 
be  proved  by  autopsy  to  render  it  certainly  correct. 


236  OPEN  FRACTUEES  AND  SUPPURATION  OF  BONE. 

Tlie  treatment  of  complicated  fractures  is  one  of  the  most  diffi- 
cult things  in  surgery.  Years  ago  a  complicated  fracture  was 
usually  an  indication  for  amputation,  the  dangers  being  thereby  so 
much  diminished  ;  and  by  the  modes  of  treatment  then  in  vogue 
more  patients  were  saved  by  amputation  than  by  conservative  treat- 
ment. Later,  as  open  treatment  of  wounds  and  fixed  dressings 
came  into  use,  indications  for  primary  amputation  were  limited  ; 
and  conservatism  was  encouraged  by  the  good  results  from  plaster 
dressings,  and  aiding  the  escape  of  secretion  by  leaving  the  wound 
open,  by  drainage,  by  counter-openings,  etc.  Perhaps  we  have 
gone  to  the  opposite  extreme,  and  may  now  amputate  too  rarely  ; 
and  with  the  idea  that  open  treatment  prevents  decomposition,  and 
that  inflammation  is  reduced  by  absolute  rest,  conservative  practice 
may  be  carried  too  far,  and  the  patient  be  exposed  to  various  dan- 
gers that  we  cannot  control,  and,  even  when  healing  is  complete,  he 
may  have  a  useless,  misshapen  limb,  that  may  be  more  of  a  burden 
than  benefit. 

Neither  the  oj^en  treatment  nor  fixed  dressings  entirely  remove 
the  dangers  of  acute  progressive  inflammations  or  of  secondary 
suppurations,  and  their  results,  septicaemia  and  pyremia  ;  many  pa- 
tients died  of  these  complications  in  spite  of  treatment  by  ice,  im- 
mersion, or  drainage.  It  is  only  of  late,  since  the  antiseptic  treat- 
ment has  been  so  thoroughly  carried  out,  that  the  treatment  of 
complicated  fractures  is  really  favorable.  This  limits  the  indica- 
tions for  amputation  almost  to  those  cases  where  recovery  would 
result  with  a  useless  limb. 

In  the  conservative  treatment  of  complicated  fractures  we  wish 
to  avoid — 1.  Retention  of  the  secretions  of  the  wound  ;  2.  Putrid 
decomposition  in  the  wound,  with  its  local  and  general  conse- 
quences ;  3.  Secondary  progressive  suppurations  in  the  wound.  As 
the  impulse  for  decomposition,  by  the  entrance  of  qrganized  excit- 
ers of  putrefaction  from  without,  is  usually  given  at  the  time  of 
injury,  the  chief  point  of  treatment  is  disinfection  of  the  recent 
wound,  to  get  rid  of  germs  already  in  and  to  destroy  and  remove 
all  substances  that  favor  the  development  of  micrococci,  es2:)ecially 
the  secretions  from  the  wound.  Of  course,  it  is  not  always  easy  to 
fulfil  this  double  indication.  In  some  cases  with  gaping  wounds 
and  superficial  division  of  the  bone,  made  by  cutting  machines, 
etc.,  simply  washing  out  the  wound  with  antiseptic  solutions  may 
prevent  infection  and  decomposition.  You  must  learn,  in  the  clinic, 
to  distinguish  such  cases  from  severe  injuries  ;  in  case  of  doubt  it 
is  better  to  be  unnecessarily  careful  in  disinfecting. 

In  most  cases  complicated  fractures  are  not  readily  accessible  to 


TREATMENT   OF   COMPLICATED   FRACTURES.  237 

examination  and  treatment,  the  wound  of  the  skin  being  too  small 
to  allow  satisfactory  inspection.  The  first  thing  is  to  determine 
the  extent  of  the  injury  ;  for  instance,  of  fracture  of  the  femur 
due  to  concussion.  The  jDatient  is  brought  into  the  hospital  just  as 
he  was  found,  except  that  the  leg  has  been  fastened  to  an  impro- 
vised splint.  A  cursory  examination  shows  that  there  is  an  injury 
of  the  bone  ;  the  patient  or  his  companions  may  say  the  bone  is 
broken.  To  make  an  accurate  examination  and  ajjply  a  permanent 
dressing  it  is  well  to  anaesthetize  the  patient,  unless  this  is  contra- 
indicated  by  his  condition  of  acute  anaemia,  shock,  or  concussion 
of  the  brain  ;  then  remove  the  clothes,  temporary  dressings,  etc.  ; 
cleanse  the  wound  and  surrounding  parts  with  soap  and  warm 
water,  or,  if  necessary,  turpentine  or  ether.  Then  examine  the 
fracture  and  skin- wound  by  introducing  the  finger  (well  disinfected) 
to  determine  the  direction  of  fracture,  dislocation,  etc.,  and  to  re- 
move foreign  bodies,  loose  bone,  etc.  Then  cleanse  and  disinfect 
the  wound  ;  for  this  purpose  it  is  often  necessary  to  enlarge  the 
skin-wound  ;  of  course  this  is  to  be  done  in  the  direction  where  few- 
est vessels  will  be  divided,  or  mostly  in  the  long  axis  of  the  limb, 
and  the  incision  should  give  you  free  access  to  the  fractured  ends 
of  the  bone.  Now  wash  the  wound  with  a  two-per-cent.  solution 
of  carbolic  acid,  being  very  careful  to  remove  foreign  bodies  (earth, 
sand,  metals,  wood,  rags,  etc.),  blood-coagula,  shreds  of  tissue, 
bone,  etc.,  but  leaving  adherent  portions  of  bone.  'S^olkmann  ad- 
vises dislocating  both  ends  of  bone  outwardly  through  the  wound, 
carefully  cleansing  them,  cutting  off  splinters,  etc,  I  do  not  con- 
sider this  as  always  necessary,  but  the  surfaces  of  the  fi-acture 
should  be  freed  from  the  adherent  coagula  and  shreds  of  tissue. 

This  manipulation  may  start  arterial  haemorrhage,  or  there  may 
have  been  bleeding  ;  in  such  cases  the  clots  should  be  turned  out 
and  the  source  of  haemorrhage  sought,  the  bleeding  point  caught 
with  forceps  and  ligated  with  disinfected  catgut  or  silk.  Should  a 
large  artery  be  torn,  if  we  cannot  ligate  it  in  the  wound  we  should 
do  so  in  the  continuity,  but  this  is  rarely  necessary.  Bleeding  from 
the  medulla  of  the  bone  or  capillaries  of  the  soft  parts  may  be  ar- 
rested by  iiTigation  with  cold  solutions  of  carbolic  acid,  elevation 
of  the  limb,  or  very  hot  water,  125°  Fahr. 

If  the  wound  has  been  cleansed  so  that  the  injection  return  un- 
colored,  you  reduce  the  fracture  by  extension  and  counter-extension 
and  pi-essure  on  the  ends  of  the  bone.  All  obstacles  to  exact  repo- 
sition should  be  removed,  bone  splinters  cut  off,  tendons  and  fasciae 
between  the  fragments  moved  to  one  side  or  cut,  and  then  sewed 
together.     The  reduction  being  completed,  examine  again  with  the 


238  OPEN  FRACTURES  AND  SUPPURATION  OF  BONE. 

fino-er  for  any  j^ockets  or  spaces  that  should  be  drained  or  have 
counter-openings.  When  a  counter-opening  is  required,  make  it  as 
nearly  opposite  the  fracture  as  jjossible  ;  pockets  should  be  opened 
at  their  deepest  point,  and  the  drainage-tubes  led  out  the  shortest 
way.  Long  drains,  obliquely  through  the  wound,  are  easily  ob- 
structed, and  if  not  removed  at  the  right  time  cause  iistuloe  ;  they 
should  not  be  used.  As  a  general  rule,  drainage-tubes  should  be  as 
short  as  possible,  and  perpendicular  to  the  surface. 

When  the  drainage-tubes  have  been  introduced,  and  secured  by 
a  safety-pin  or  suture,  we  should  see  that  they  act  properly  by  in- 
jecting a  two-per-cent.  solution  of  carbolic  acid  and  noticing  if  it 
escapes  well.  Xow  disinfect  the  whole  wounded  surface  with  a 
five-  to  eight-per-cent.  solution  of  chloride  of  zinc,  to  destroy  any 
germs  that  may  have  entered  already,  and  to  induce  a  thin  crust  on 
the  surface  that  may  protect  it  from  infectious  matters  ;  this  "  thin 
crust "  is  a  grayish-white  coating,  due  to  coagulation  of  the  tissue- 
fluids,  and  does  not  interfere  with  healing  by  first  intention.  When 
the  ends  of  the  bone  have  been  brought  into  position,  and  the 
drainage-tubes  arranged,  you  may  unite  the  wound  made  by  inci- 
sion by  sutures  deep  and  superficial  ;  parts  that  have  been  much 
crushed  will,  of  course,  be  left  free,  and  the  edges  are  not  to  be 
united  so  as  in  any  way  to  interfere  with  escape  of  secretion  or 
cause  tension.  These  sutures  cause  as  much  as  jsossible  to  heal  by 
first  intention.  The  case  is  now  ready  for  dressing,  and  Xisfer^s 
dressing,  with  plenty  of  gauze,  may  be  applied,  making  regular 
compression  and  covering  the  limb  for  some  distance  around  the 
fracture ;  then  apply  gutta-percha  paper,  wadding,  and  another 
bandage  ;  outside  of  this  Z/ister^s  dressing  we  may  place  splints  of 
wood,  gutta-percha,  zinc,  pasteboard,  starch  bandage,  etc.,  or  in 
fractures  of  the  femur,  with  the  antiseptic  dressing,  we  may  use 
£uch''s  extension  apparatus.  Bear  in  mind  that  the  fate  of  the  case 
may  depend  on  this  first  dressing,  as  the  local  and  general  complica- 
tions of  compound  fractures  are  due  exclusively  to  infection  of  the 
wound  from  the  entrance  of  ferments.  If  at  the  first  dressing  we 
succeed  in  fully  disinfecting  the  wound,  and  removing  all  foreign 
bodies,  blood-coagula,  etc.,  the  patient  will  be  in  about  the  same 
condition  as  after  a  simple  fracture.  The  absorption  of  the  unde- 
composed  secretion  from  the  wound  has  little  effect  ;  the  wound, 
properly  drained  and  brought  together  by  the  bandage,  may  unite 
mostly  by  first  intention,  without  interfering  with  the  escape  of  se- 
cretion. Usually  between  the  ends  of  the  bone,  and  filling  the 
whole  cavity,  there  is  a  blood-clot  coming  from  the  vessels  of  the 
medulla  and  the  soft  parts  after  the  dressing  has  been  applied  ;  this 


TREATMENT   OF   COMPLICATED   FRACTURES.  239 

prevents  the  entrance  of  air  to  the  cavity  ;  if  this  clot  escapes  in- 
fection from  organic  germs  it  plays  the  part  of  the  coagulated  fibrine 
between  the  edges  of  a  simple  incised  wound  ;  wandering  cells 
enter  it  new  vessels  throw  out  loops,  and  in  normal  cases  the  coagu- 
lum  becomes  organized  and  serves  as  the  first  provisional  union  of 
the  fractured  ends.  If  the  first  dressing  has  been  successful,  the 
subsequent  treatment  is  very  simple  ;  in  twenty-four  hours  the 
dressing  is  changed,  to  get  rid  of  the  portions  impregnated  with 
bloody  serum  ;  the  second  dressing  may  stay  on  till  the  fourth  or 
fifth  day,  or  till  the  secretion  shows  through.  If  all  goes  well,  many 
or  all  of  the  drainage-tubes  may  be  removed,  and  subsequent 
dressings  may  be  left  on  a  week  or  two,  till  the  wound  is  all  healed. 
If  there  be  still  some  granulations,  they  may  be  treated  with  salves. 

If  the  first  dressing  has  not  succeeded,  or  if  decomposition  had 
already  begun  in  the  wound,  we  cannot  expect  much  benefit  from 
Lister's  dressing  ;  on  removing  the  first  dressing  you  may  notice 
that  the  secretion  smells  bad,  the  patient  complains  of  pain,  there 
is  swelling  about  the  wound,  and  sensitiveness  to  touch  ;  pressure 
brings  out  dark,  decomposing  blood  w^hich  has  active  phlogogenous 
and  pyrogenous  properties.  Should  you  decide  to  attempt  arresting 
this  decomposition,  the  only  way  is  to  open  the  wonnd  and  cleanse 
it  with  a  strong  solution  of  carbolic  acid  or  chloride  of  zinc,  but 
such  attempts  rarely  succeed.  Blood-clots  infiltrated  in  the  soft  parts 
form  so  many  foci  for  development  of  coccobacteria  ;  you  cannot 
disinfect  the  wound  perfectly  because  its  borders  have  been  infil- 
trated, and  micrococci  have  entered  the  spaces  between  the  connec- 
tive tissue. 

Where  the  first  JOlster''s  dressing  has  not  succeeded,  you  had  bet- 
ter relinquish  it  and  resort  to  the  open  treatment  ;  remove  the  su- 
tures where  necessarj^,  fill  the  cavity  with  charpie  wet  with  Huroio's 
solution,  and  over  the  whole  apply  compresses  wet  with  the  same 
fluid.  Sometimes  even  this  does  not  answer,  or  you  do  not  see  the 
fracture  till  the  third  or  fourth  day,  and  find  the  whole  wound  de- 
composing, and  about  the  fracture  there  is  marked  swelling  and 
infiltration,  then  you  may  best  try  permanent  irrigation  with  J3u- 
roici's  solution  ;  by  this  you  may  hope  to  arrest  the  decomposition, 
and  at  least  to  escape  the  complications  of  septic  phlegmon  and 
secondary  suppurations.  In  such  cases  the  utmost  attention  is  re- 
quired to  recognize  at  once  any  retention  of  secretion  or  accumula- 
tion of  pus,  and  render  them  harmless  by  drainage  or  counter-open- 
ings. Of  course  there  is  no  hope  of  healing  by  first  intention  in 
such  cases,  and  we  may  be  glad  if  the  inflammation  and  suppura 
tion  remain  limited  to  the  wound,  and  do  not  spread. 


240  OPEN  FRACTURES  AND  SUPPURATION  OF  BONE. 

When  the  wound  is  filled  with  gi-anulations  the  permanent  irri- 
gation may  be  abandoned,  but  the  drainage-tubes  be  left  in  position 
for  a  time  ;  of  course,  healing  goes  on  more  slowly  than  under  nor- 
mal circumstances,  and  there  is  more  danger  from  complications 
than  when  Lister''s  dressing  is  used. 

Of  late  iodoform  has  been  extensively  employed  in  surgery, 
and  among  other  cases  in  compound  fractures.  The  peculiar  action 
of  iodoform  on  proliferating,  fungous  granulations,  will  be  treated 
of  hereafter ;  here  it  is  enough  to  say  it  has  a  very  decided  anti- 
septic action,  probably  because  its  contact  with  the  tissues  induces 
continuous  formation  of  iodine  ;  for  iodine  may  be  detected  in  the 
secretions  of  patients  treated  with  iodoform.  This  drug  is  a  yellow 
crystalline  powder,  insoluble  in  water  ;  it  is  usually  sprinkled  on  in 
substance,  or  wounds  are  packed  with  it,  Lister^s  dressing  being 
applied  over  it.  In  compound  fractures,  extensive  contused  wounds, 
especially  when  ragged,  after  due  preparation  the  cavity  may  be 
filled  with  iodoform,  and  the  dressing  left  on  till  the  secretion 
comes  through.  A  peculiarity  which  renders  the  use  of  iodoform 
objectionable  for  some  persons  is  its  smell.  Success  with  iodoform 
treatment  depends  a  good  deal  on  whether  a  wound  is  suflSciently 
accessible  ;  if  not  you  may  have  to  resort  to  permanent  antiseptic 
irrigation. 

Sometimes  several  weeks  after  the  injury  there  will  be  swelling, 
profuse  suppuration,  and  high  fever,  which  may  be  due  to  partial 
necrosis  of  sharp  fragments  ;  if  so,  the  attempt  should  be  made 
during  anaesthesia  to  extract  the  offending  bone  ;  otherwise  the 
necrosed  fragments  should  be  left  to  be  pushed  out  by  the  granula- 
tions, and  no  unnecessary  attempts  at  sounding  should  be  made 
until  the  wound  has  become  like  a  chronic  bone  fistula. 

Healing  of  compound  fractures  is  always  tedious — it  may  take 
far  more  than  twice  as  long  as  a  simple  fracture  ;  we  should  not 
allow  the  patient  to  use  the  limb  till  manual  examination  shows  it 
is  firm.  The  disappearance  of  callus,  and  other  changes,  occur  as  in 
simple  fractures.] 


APPENDIX  TO  CHAPTEKS  V.  AND  YI. 

LECTURE     XVII. 

1  Retarded  Formation  of  Callus  and  Development  of  Pseudarthrosis. — Causes  often 
uQknown. — Local  Causes.  —  Constitutional  Causes.  —  Anatomical  Conditions.— 
Treatment :  internal,  operative ;  Criticism  of  Methods.  2.  Obliquely-united 
Fractures ;    Rebreaking,  Bloody  Operations. — Abnormal  Development  of  Callus. 

1.— RETARDED   DEVELOPMENT  OF  CALLUS    AND    FORMATION  OF  A  SO- 
CALLED  FALSE  JOINT— A  SO-CALLED  PSEUDARTHROSIS. 

Under  some  circumstances,  \vhicli  we  do  not  always  sufficiently 
understand,  a  fracture  is  not  consolidated  after  the  laj^se  of  the  usual 
time ;  indeed,  it  may  not  consolidate  at  all,  but  the  seat  of  fracture 
may  remain  painless  and  movable,  which  of  course  impairs  the  func- 
tion of  the  limb,  even  to  the  point  of  entire  uselessness.  A  short 
time  since,  a  strong  farmer-boy,  with  simple  subcutaneous  fracture  of 
the  leg  without  dislocation,  entered  the  hospital ;  as  usual,  a  plaster- 
bandage  was  applied  and  renewed  in  fourteen  days.  Six  weeks  after 
the  fracture  the  dressing  was  removed  altogether,  in  the  expectation 
that  union  had  taken  place ;  but  the  point  of  fracture  was  still  per- 
fectly movable,  nor  could  any  callus  be  felt.  I  here  tried  the  sim- 
plest remedy  in  such  cases,  I  narcotized  the  patient,  and  then  rubbed 
the  fragments  strongly  together  till  crepitation  could  be  distinctly 
perceived ;  then  I  applied  another  plaster-dressing,  and  on  removing 
this  in  four  weeks  found  the  fracture  tolerably  firm.  I  placed  the  pa- 
tient in  a  fracture-box,  and,  without  placing  any  bandage  on  the  leg, 
had  its  anterior  surface  painted  daily  with  strong  tincture  of  iodine. 
After  this  had  been  continued  a  fortnight,  the  fracture  was  perfectly 
firm  ;  the  patient  now  stood  with  the  aid  of  crutches,  and  in  a  short 
time  was  dismissed  cured.  I  know  of  two  other  cases  from  the  prac- 
tice of  colleagues,  where  simple  fractures  in  very  healthy  young  per- 
sons did  not  consolidate,  but  formed  pseudarthroses.  Such  occur- 
rences are  to  be  regarded  as  very  rare ;  usually  there  is  some  peculiar 
17 


242  PSEUDARTHEOSIS. 

cause,  such  as  disease  of  the  bone,  that  induces  false  joint.  There  are 
certain  fractures  of  the  human  skeleton  which  from  various  causes 
very  rarely  unite  by  bony  callus ;  among  these,  are  intracapsular  frac- 
tures of  the  neck  of  the  femur,  neck  of  the  humerus,  and  fractui'es  of 
the  olecranon  and  patella.  When  fractured  transversely  the  two  latter 
bones  separate  so  far  that  the  osseous  substance  formed  on  the  two 
ends  cannot  meet,  so  that  only  a  ligamentous  union  can  take  place  be- 
tween these  two  parts  of  bone.  When  fractured  within  the  capsule 
.the  head  of  the  femur  has,  it  is  true,  a  supply  of  blood  through  a 
small  artery  which  enters  it  through  the  ligamentum  teres,  but  this 
source  of  nutrition  is  very  slight,  consequently  the  production  of  bone 
from  the  small  fragments  is  slight.  In  fracture  of  the  head  of  the 
humerus  within  the  capsule,  in  the  rare  case  of  part  of  the  head  be- 
ing entirely  detached  from  the  rest  of  the  bone,  this  portion  of  bone 
will  receive  no  supply  of  blood,  and  will  act  as  a  foreign  body ;  its 
union  can  scarcely  be  expected.  In  the  above  examples,  we  regard 
non-union  so  much  as  the  rule  that  we  do  not  usually  call  them  cases 
of  pseudarthrosis.  But  I  wish  to  show  you  that  there  may  be  purely 
local  causes  that  predispose  to  pseudarthrosis ;  among  these  espe- 
cially belongs  complete  loss  of  large  pieces  of  bone,  after  the  removal 
of  which,  in  open  fractures,  there  may  be  so  large  a  defect  that  it  will 
not  be  again  filled  by  new  bone-tissue.  Protracted  suppuration  with 
ulcerative  destruction,  and  extensive  detachment  of  the  ends  of  the 
fragments,  nsay  also  lead  to  pseudarthrosis.  Moreover,  the  treatment 
is  occasionally  blamed ;  too  loose  a  dressing,  or  none  at  all,  and  too 
early  motion,  are  occasionally  accused.  On  the  other  hand,  it  has 
been  asserted  that  too  continued  application  of  cold,  the  simultaneous 
ligation  of  large  arteries,  and,  lastly,  too  tight  a  dressing,  may  inter- 
fere with  proper  development  of  bony  callus.  All  this  alone  does  not 
necessarily  lead  to  pseudarthrosis,  but  may  act  as  a  second  cause  when 
the  general  conditions  of  nutrition  in  the  organism  predispose  to  it. 
Of  the  general  predispositions  and  bone  diseases,  the  following  may 
be  mentioned  as  disposing  to  pseudarthrosis :  bad  nutrition,  debility 
from  repeated  losses  of  blood,  specific  diseases  of  the  blood,  such  as 
scorbutis,  or  cancerous  cachexia.  Of  the  diseases  of  the  bones,  it  is 
chiefly  osteomalacia,  atrophy  of  the  cortical  substance,  with  enlarge- 
ment of  the  medullary  cavity,  in  which,  as  already  mentioned,  in  certain 
stages  there  is  not  only  decided  fragilitas  ossium,  but  in  which  also  the 
chances  for  reunion  are  -slight.  I  have  stated  all  this,  because  it  is  gen- 
erally accepted,  although,  on  sharp  critical  examination,  some  of  the 
above-mentioned  predisposing  causes  for  pseudarthrosis  are  of  very 
different  value,  while  the  significance  of  others  is  entirely  doubtful. 
In  the  same  way  it  is  a  common  belief  that  fractures  are  not  consoli- 


APPENDIX   TO   CHAPTERS  V,   AND   VI.  243 

dated  in  pregnant  females.  This  is  not  true  in  all  cases ;  I  have  my. 
self  seen  numerous  fractures  unite  in  pregnant  women,  only  once 
hardening  of  the  callus  was  delayed  a  few  weeks  in  a  fracture  of  the 
lower  end  of  the  radius,  which  was  recognized  late,  as  might  also 
occur  in  women  not  pregnant,  or  in  men. 

The  abnormity  of  the  healing  process  in  case  of  pseudarthrosis  is 
not  due  to  the  non-formation  of  callus,  but  to  the  failure  of  ossifica- 
tion in  the  new  formation.  The  substance  connecting  the  fragments 
becomes  a  more  or  less  rigid  connective  tissue,  by  which  the  ends  of 
the  bone  are  held  more  or  less  closely  together.  If  the  fragments  lie 
so  close  that  tliey  come  in  contact  on  motion  of  the  limb,  a  cavity 
with  smooth  walls,  filled  with  sero-mucous  fluid,  forms  between  them 
in  the  uniting  tissue ;  and,  on  the  fractured  ends,  cartilage  has  been 
found,  so  that  there  was,  in  fact,  a  sort  of  new  joint.  Tliis  does  not, 
however,  occur  very  often,  but  in  most  cases  we  have  simply  a  firm 
connecting  mass,  which  sinks  directly  into  the  fragments  like  a 
tendon.  When  such  a  pseudarthrosis  is  in  a- small  bone,  such  as  the 
cla\acle,  or  one  of  the  bones  of  the  forearm,  the  disturbance  of  func- 
tion is  always  bearable  ;  but,  if  it  be  located  in  the  arm,  thigh,  or 
leg,  of  course  there  must  be  considerable  impairment  of  function. 
In  some  cases  it  is  possible,  by  suitable  supporting  apparatus,  to  give 
the  limb  the  necessary  firmness ;  in  other  cases  we  cannot  do  this  at 
all,  or  only  incompletely,  so  that  for  a  long  time  attempts  have  been 
made  to  cure  this  disease  by  operation,  that  is,  b}*  inducing  ossifica- 
tion. Before  passing  to  the  methods  used  for  this  purpose,  we  must 
mention  the  attempts  made  to  prevent  false  joint,  and  to  cure  it,  when 
once  established,  by  internal  remedies.  Preparations  of  lime  are 
chiefly  used  for  this  purpose.  Phosphate  of  lime  was  given  internally 
in  the  shape  of  powder ;  lime-water  was  given  in  milk,  but  without 
much  benefit.  Of  the  lime  given  in  this  way,  little  is  absorbed,  and, 
of  this  superfluous  lime  taken  into  the  blood,  much  was  excreted 
through  the  kidnej'S,  so  that  the  pseudarthrosis  had  little  good  from 
it.  We  may  expect  more  from  general  regulation  of  diet,  and  pre- 
scribing articles  of  food  that  contain  lime.  Residence  in  pure  country 
air,  and  milk-diet,  are  to  be  recommended ;  but  you  must  not  expect 
too  much  from  these  remedies,  especially  in  a  fully-formed  false  joint 
tliat  has  existed  for  years.  In  a  recently-published  and  very  interest- 
ing work  by  Wegner,  it  is  shown,  by  a  number  of  experiments,  that 
by  continued  administration  of  small  doses  of  phosphorus  the  forma- 
tion cf  callus  about  fractures  is  particularly  luxurious  and  hard,  as  well 
as  that  in  growing  animals  the  portion  of  bone  formed  during  the  ad- 
ministration of  phosphorus  is  unusually  dense  and  hard,  and  very 
rich  in  chalky  salts.     These  experiments  would  lead  us  to  try  phos- 


244  PSEUD  ARTHROSIS. 

phorus  in  patients  Avith  pseudartlirosis,  especially  in  tlie  earliei 
stages ;  of  course,  we  sliould  be  very  careful  of  this  remedy,  which 
may  be  so  dangerous  when  carelessly  used.  Ihe  local  remedies  all 
aim  at  inducing  inflammation  in  the  ends  of  the  bone  and  parts 
around,  because  experience  shows  that  most  inflammations  in  the 
bone,  especially  subcutaneous  traumatic  ones,  induce  formation  of 
bone  in  their  immediate  vicinity.  Ihe  remedies  employed  vary  very 
greatly.  We  have  already  mentioned  the  proposals  to  leave  the 
limb  without  dressing,  so  as  to  avoid  interfering  with  the  formation 
of  the  external  callus  by  pressure,  also  the  rubbing  together  of  the 
fragments,  and  painting  with  iodine ;  with  the  same  view  (viz.,  of 
irritating  the  fragments),  we  may  apply  blisters  and  the  hot  iron  to 
the  part  of  the  limb  corresponding  to  the  fjacture.  By  the  following 
remedies  we  act  more  on  the  intermediate  ligamentous  tissue  :  long, 
thin  acupuncture-needles  are  passed  into  the  ligamentous  band,  and 
left  there  for  a  few  days  to  excite  irritation ;  we  may  connect  the 
ends  of  two  of  these  needles  with  the  poles  of  a  galvanic  battery,  and 
pass  an  electrical  current  as  an  irritant.  Tliis  proceeding  is  called  elec- 
tro-puncture  /  it  is  little  used.  "NYe  may  also  pass  a  thin,  small  tape,  or 
several  threads  of  silk  (a  so-called  seton  or  a  strong  ligature),  through 
the  ligamentous  tissue,  and  leave  it  there  till  there  is  free  suppuration 
around  it.  The  following  operations  attack  the  bone  more  directly  ; 
they  are  quite  numerous  :  For  instance,  a  narrow  but  strong  knife  is 
passed  as  deep  as  the  fracture,  and  the  ligamentous  tissue  is  shaved 
first  from  the  end  of  one  fragment,  then  from  the  t  ther,  without  en- 
larging the  skin-wound.  This  is  called  the  subcutaneous  bloody  fresh- 
ening of  the  fragments.  Or  we  may  make  an  incision  down  to  the 
bone,  dissect  out  the  two  fragments,  perforate  them  close  to  the  fract- 
ured end,  and  pass  a  sufficiently  thick  lead  wire  through  the  perfora- 
tions, twist  the  ends  together,  so  as  to  approximate  the  fragments,  or 
else,  after  making  an  incision,  we  may  saw  off  a  tliin  piece  from  each 
fragment,  and  treat  the  resulting  wound  like  an  open  fracture  ;  and  to 
this  operation,  resection  of  the  fragments,  we  may  add  the  application 
of  a  suture  of  the  hone.  The  following  operation  originates  with  Dicf- 
fenbach :  Corresponding  to  the  ends  of  the  fragments  he  makes  two 
small  incisions  down  to  the  bone,  then  he  perforates  the  ends  of  tlie 
bone  close  to  its  borders,  and  with  a  hammer  drives  ivory  pegs^  of 
suitable  thickness,  into  the  perforations.  The  consequence  is,  a  for- 
mation around  these  foreign  bodies  of  new  bone,  which,  Avhen  ex- 
tensive enough,  as  it  may  always  be  made  in  the  course  of  time  by 
repeating  the  operation,  causes  firm  union.  I  will  here  mention  that, 
when  extracted  in  a  few  weeks,  these  i\  ory  jiegs  look  rough  and 


APPENDIX  TO  CHAPTERS  V.  AND  YI.  245 

corroded  at  the  points  Avliere  tliey  were  in  contact  with  the  bone, 
while  the  perforation  in  which  they  hiy  is  mostly  filled  with  granula- 
tions ;  occasionally  the  pegs  are  not  removed ;  the  openings  through 
which  they  were  introduced  heal.  This  proves  absolutely  that  dead 
hone,  among  which  ivory  is  to  be  classed,  tnay  be  dissolved  and  reab- 
sorbed by  the  growing  osseous  granulations.  We  shall  hereafter  have 
frequent  occasion  to  return  to  this  much-contested  question,  which  is 
very  important  in  some  bone-diseases ;  we  have  already  spoken  of 
the  theoretical  causes  of  this  reabsorption  (p.  197).  S.  v.  Langen- 
beck  has  modified  this  operation  of  Dieffenhach  by  using  metal 
screws  instead  of  ivory  pegs;  immediately  after  the  operation  he 
fastens  these  screws  to  an  apparatus,  which  keeps  the  fragments  im- 
movable. After  all  these  operations,  a  suitable  dressing  must  be 
applied  to  keep  the  fragments  firm. 

The  modes  of  operation  in  pseudarthrosis,  of  which  I  have  only 
mentioned  the  principal  ones,  are,  as  you  see,  quite  numerous;  and,  if 
the  results  of  treatment  corresponded  to  the  number  of  remedies,  this 
would  belong  to  the  most  curable  class  of  diseases.  But  in  medicine 
you  may  generally  take  it  that,  with  the  increase  in  number  of  reme- 
dies for  a  disease,  their  value  decreases.  Eas}'  and  certain  as  some 
forms  of  pseudarthosis  are  to  cure,  others  are  just  as  difficult ;  nor  are 
all  the  different  methods  suited  to  the  same  case.  In  the  first  place, 
the  operations  vary  greatly  as  to  danger,  being  much  more  dangerous 
in  limbs  with  thick  soft  parts,  especially  in  the  thigh,  than  in  others ; 
and,  as  may  be  readily  supposed,  the  non-bloody  operations  are  less 
dangerous  than  the  bloody ;  those  made  with  a  small  wound  less  so 
than  those  with  larger.  As  regards  efficacy  and  certainty,  I  consider 
the  introduction  of  a  bone  suture  and  resection  as  those  which,  even 
in  the  worst  cases,  give  proportionately  the  quickest  results,  but 
which  still  have  all  the  elements  of  danger  of  a  fracture  complicated 
by  a  wound.  The  treatment  with  ivory  pegs  is  less  dangerous,  ex- 
cept in  the  thigh,  where  every  false  joint  is  dangerous,  and  I  think  it 
would  accomplish  the  object  in  most  cases,  if  the  ojDeration  were 
repeated  often  enough.  I  have  seen  good  results  from  this  treat- 
ment, and  from  Von  LangenbecH' s  screw  apparatus,  as  well  as  from 
the  bone  suture. 

In  pseudarthrosis  of  the  thigh  the  question  may  seriously  be 
asked,  if  we  should  not  prefer  amputation  at  the  point  of  the  false 
joint  (which  is  of  favorable  prognosis)  to  any  other  dangerous  or 
doubtful  operation.  This  question  only  the  peculiarities  of  the  in- 
dividual case  can  decide.  In  some  cases  the  safe  aid  of  a  suitable 
splint  apparatus,  made  by  a  skilful  instrument-maker,  is  preferable  to 
any  operation. 


246  OBLIQTJELr-UNITED   FRACTURES. 

2.— OBLIQUEL"k  -UNITED  FRACTURES. 

Although,  with  the  progress  made  in  the  t'-eatment  of  fractures,  it 
is  now  rare  for  union  to  occur  in  so  obhque  a  direction  as  to  render 
the  limb  entirely  useless,  still,  cases  from  time  to  time  arise  where, 
in  spite  of  the  greatest  care  of  the  surgeon,  in  fractures  with  open 
wounds,  dislocation  cannot  be  avoided,  or  else,  from  carelessness  or 
great  restlessness  of  the  patient  and  loose  application  of  the  dress- 
ings, a  considerable  obliquity  in  the  position  of  the  fracture  remains. 
In  many  cases  this  is  so  slight  that  the  patients  do  not  care  to  get 
rid  of  the  deformity;  improvement  of  the  position  would  only  be 
desired  in  cases  where,  from  considerable  obliquity  or  shortening  of  a 
foot  or  leg,  the  movements  are  decidedly  imjDaired.  There  are  vari- 
ous means  by  which  we  may  greatly  improve  or  entirely  get  rid  of 
these  deformities.  If,  during  the  process  of  union,  we  notice  that  the 
fragments  are  not  exactly  coapted,  we  may  undertake  the  adjustment 
at  any  time  in  simple  subcutaneous  fractures.  If,  in  an  open  fracture, 
obliquity  of  the  fragments  has  taken  place  under  the  first  dressing,  I 
strongly  urge  you  not  to  try  to  rectify  it  before  the  wound  has  healed ; 
you  would  thus  break  up  the  deeper  granulations,  and  the  severest 
inflammation  might  again  be  excited.  In  fractures  that  have  long 
suppurated,  the  callus  long  remains  soft,  so  that  you  may  always  sul)- 
sequently  accomplish  a  gradual  improA'ement  in  position  by  pri)per1y 
padding  the  splints  first  in  one  place,  then  in  another,  or  perliaps  by 
continued  extension  with  weights.  If  the  fracture  be  fully  consoh- 
dated  in  an  oblique  position,  we  liave  the  following  remedies  for  its 
improvement : 

1.  Correction  bj-  bending  the  callus,  by  infraction  •  for  this  pur- 
pose we  ancestlietize  the  patient,  and  with  the  hands  attempt  to  bend 
the  limb  at  the  point  of  fracture ;  if  we  succeed  in  so  doing,  we  apply 
a  firm  dressing  with  the  hmb  in  the  improved  position.  This  method, 
so  free  from  danger,  can  only  be  successful  while  the  callus  is  still  soft 
enough  to  be  bent ;  hence  it  can  only  be  done  soon  after  the  fracture. 

2.  Complete  breaking  up  of  the  ossified  callus.  This  also  may 
sometimes  be  done  by  the  hands  alone,  but  frequently  other  mechan- 
ical means  will  have  to  be  resorted  to.  For  this  purpose  various  ap- 
paratuses have  been  constructed,  such  as  lever  and  screw  machines  of 
considerable  power ;  one  of  the  most  terrible  bears  the  name  of  "  dys- 
morphosteopalinklastes.-'  All  these  apparatuses  should  only  be  used 
with  the  greatest  care,  so  as  not  to  cause  too  much  bruising  and  con- 
sequent necrosis  of  the  sldn  at  the  point  where  the  machine  is  applied 
on  which  the  hmb  rests.  For  the  not  unfrequent  obhquely-united 
fractures  of  the  thigh,  i\iQ  forced  extension  of  A.  War/ner  (by  the 


APPENDIX   TO    CHAPTERS   V.  AND  VI.  247 

ajjparatus  of  Schneider  and  Menel,  wliicli  we  also  employ  for  reduc- 
ing old  dislocations)  has  been  resorted  to  with  success.  The  follow- 
ing illustration  will  fully  explain  the  mechanical  eifect  of  this  exten- 
sion :  If  you  have  a  bent  rod,  and  let  a  strong  man  take  hold  of  each 
end  and  draw,  the  rod  will  break  at  the  point  where  it  is  bent  most. 
If  a  ncAV  fracture  of  the  thigh  has  been  caused  by  indirect  force  at  the 
bent  part,  and  the  fragments  be  adjusted  in  a  sti'aight  position,  you 
apply  a  plaster-dressing  at  once  while  the  limb  is  still  held  in  the  ma- 
chine. As  far  as  our  present  experience  goes,  this  method  appears  to 
be  entirely  free  from  danger,  but  only  suited  for  the  thigh  ;  in  a  case 
of  very  angular  union  of  a  fracture  of  the  leg,  where  I  advised  this 
treatment,  the  break  caused  by  the  extension  was  not  in  the  old  seat 
of  fracture,  but  near  it, 

3.  The  bloody  operations  on  the  bone,  of  which  there  are  two  in 
use,  are  more  dangerous ;  the  first  of  these  is  the  subcutaneous  oste- 
otomy of  _B.  V.  Langenheck.  This  consists  in  making  a  small  incis- 
ion down  to  the  bone  at  the  bent  part,  introducing  a  medium-sized 
gimlet  through  this  opening  and  perforating  the  bone,  without,  how- 
ever, piercing  the  soft  parts  on  the  opposite  side ;  then  draw  out  the 
perforator,  and  pass  a  small,  fine  saw  through  the  perforation,  and  saw 
the  bone  transversely,  first  to  one  side,  then  to  the  other,  till  you  can 
break  the  rest  of  the  bone  with  your  hand ;  now  the  bone  is  to  be 
straightened  and  the  injury  treated  as  a  complicated  fracture.  This 
operation  has  only  been  done  on  the  leg,  but,  so  far  as  I  know,  always 
with  good  resiilt.  It  may  also  be  done  by  not  making  the  adjust- 
ment till  suppuration  begins,  and  the  callus  has  thus  been  softened 
and  partly  reabsorbed.  For  V.  LangenhecJc's  instruments  we  may 
advantageously  substitute  fine  chisels,  as  recommended  by  Gross,  for 
dividing  the  callus  from  a  small  exposed  portion  of  the  bone. 

4.  Lastly,  we  may  employ  the  method  of  H/iea  J^arton,  whicli 
consists  in  exposing  the  bone  by  a  large  incision  through  the  skin  at 
the  point  of  curvature,  and  sawing  out  a  wedge-shaped  piece  in  such 
a  way  that  the  broad  part  of  the  wedge  shall  correspond  to  the  con- 
vexity, the  point  to  the  concavity  of  the  abnormal  curvature  of  the 
bone.     This  method  also  shows  good  results. 

On  the  whole,  the  non-bloody  are  to  be  preferred  to  the  bloody 
methods,  if  they  do  not  cause  too"  much  contusion;  but  the  latter  are 
less  dangerous  than  brealdng  up  fractures  with  strongly-contusing 
apparatuses. 

If  the  deformity,  especially  of  a  foot,  be  so  great,  in  diflTcrent 
directions,  that  none  of  the  above  methods  offer  much  prospect  of  cure, 
we  may  have  to  resort  to  amputation  in  some  cases. 


248  OPERATIONS   FOR   OSTEOTOMY. 

In  some  few  cases  tlie  callus  is  abnormally  thick  and  extensive, 
just  as  happens  in  cicatrices  of  the  skin  and  nerves.  Do  not  be  too 
hasty  about  operating  in  such  cases,  for  slow  subsequent  reabsorp- 
tion  usually  takes  place  in  every  callus.  The  removal  of  such  callus 
masses  could  only  be  effected  with  chisel  or  saw,  and  I  should  be 
unwilling  to  decide  on  such  an  operation. 

[Operations  for  osteotomy  should  be  made  with  strict  antiseptic 
precautions,  and  these  are  not  dangerous  where  the  chisel  can  be 
used  instead  of  the  saw  :  we  escape  the  bone-dust. 

It  seems  as  if  oblique  fractures  of  the  tibia,  without  much  dis- 
placement, formed  a  large  part  of  the  cases  of  delayed  formation 
of  callus  ;  many  of  the  cases  have  had  very  little  local  reaction, 
and  have  been  placed  in  fixed  dressings  immediately  after  the  injury. 
Another  accident  is  retarded  ossification  of  callus.  Recovery  may 
seem  perfect  and  dressings  may  be  left  off,  and  after  a  day  or  two 
you  may  find  shortening  or  angular  deformity  of  the  limb.  In 
such  cases  the  callus  has  not  properly  ossified,  and  the  bone  behaves 
as  a  rachitic  bone.  After  a  time  complete  consolidation  results,  al- 
though the  deformity  may  persist.  Sometimes  pseudarthrosis  is 
attributed  to  bad  treatment,  the  dressing  has  been  too  loose,  the 
limb  not  properly  splinted,  or  it  has  been  moved  too  soon,  etc.,  etc. 
These  assertions  are  all  uncertain,  as  are  the  claims  that  proper  de- 
velopment of  callus  may  be  impeded  by  application  of  cold,  liga- 
tion of  large  arteries,  paralysis  of  the  extremities,  or  by  a  bandage 
too  firmly  applied. 

Among  the  local  means  of  treatment  may  be  mentioned  paint- 
ing the  skin  over  the  part  with  tincture  of  iodine  ;  this  induces 
plastic  infiltration  of  tissue  extending  to  the  periosteum  and  bone  ; 
blisters  and  the  cautery  act  in  the  same  way.  Another  means, 
sometimes  efficacious,  is  constriction  of  the  extremity  by  binding 
on  a  thick  compress  of  wadding  above  the  fracture  so  as  to  com- 
press the  veins  of  the  limb  and  cause  swelling  ;  after  a  few  days' 
repetition  of  this,  swelling  of  the  ends  of  the  fragment  shows 
formations  of  callus.] 


CHAPTER   VII. 
IJ^JUEIES   OF  THE  JOINTS. 

Contusion. — ^Distortion. — Opening  of  the  Joint,  and  Acute  Traumatic  Articular  Inflam- 
mation.— Variety  of  Course,  and  Results. — Treatment. — Anatomical  Changes. 

Hitherto  we  have  studied  injuries  of  simple  tissue-elements;  now 
we  must  occupy  ourselves  with  more  complicated  apparatuses. 

As  is  well  known,  the  joints  are  composed  of  two  ends  of  bones 
covered  with  cartilage  ;  of  a  sac  frequently  containing  many  appen- 
dages, pockets,  and  bulgings  ;  the  synovial  membrane,  which  is  classed 
among  the  serous  membranes ;  and  of  the  fibrous  capsule  of  the  joint 
with  its  strengthening  ligaments.  Under  some  circumstances,  all 
these  parts  participate  in  the  diseases  of  the  joint,  so  that  at  the  same 
time  we  may  have  disease  of  a  serous  membrane,  of  a  fibrous  capsule, 
as  well  as  of  cartilage  and  bone.  The  participation  of  these  different 
jDarts  varies  exceedingly  in  intensity  and  extent ;  but  I  may  state  at 
once  that  the  sjmovial  membrane  plays  the  most  important  part,  and 
that  the  peculiarity  of  joint-diseases  is  chiefly  due  to  the  closed  and 
irregular  form  of  the  synovial  sac. 

First,  a  few  words  about  crushing  and  contusion  of  the  joint.  If 
one  receives  a  heavy  blow  against  the  joint,  it  may  swell  moderately  ; 
but  in  most  cases,  after  a  few  days  of  rest  and  applications  of  lead- 
water  or  simple  cold  water,  the  swelling  and  pain  subside,  and  the 
functions  of  the  joint  are  restored.  In  other  cases,  slight  pain  and 
stiffness  remain ;  a  chronic  inflammation  develops,  which  may  lead  to 
serious  disease,  of  which  we  cannot  at  present  speak  more  fully.  If 
we  have  a  chance  to  examine  a  moderately-contused  joint,  the  patient 
having  died  perhaps  of  a  serious  injury  received  at  the  same  time,  we 
shall  find  extravasations  of  blood  in  the  synovial  membrane,  and  even 
blood  in  the  cavity  of  the  joint  itself;  in  these  contusions  without 
fracture  the  effusions  of  blood  are  rarely  so  extensive  that  the  joint  is 
tensely  filled  with  blood;  but  this  may  occur.  This  condition  is 
called  hoemarthron  (from  alua^  blood,  and  ap-&pov^  joint).  If  a  joint 
that  has  swollen  greatly  just  after  an  injury  remains  painful  for  some 


250  INJURIES   OF   THE   JOINTS. 

time,  and  feels  hot,  a  somewhat  more  active  antiphlogistic  tieatment 
is  indicated.  This  consists  in  the  application  of  leeches,  regular  en- 
velopment of  the  joint  in  wet  bandages,  causing  moderate  compres- 
sion, and  in  applying  an  ice-bladder  to  the  joint.  As  a  rule,  inflam- 
mation of  this  grade  may  be  readily  relieved,  although  chronic  dis- 
eases and  a  certain  irritability  of  the  joint  that  has  been  injured  not 
unfrequently  follow.  It  is  very  important  to  determine  whether  the 
crushing  of  the  joint  be  accompanied  by  fracture  or  fissure  of  the  end 
of  the  bone,  in  which  case,  it  would  be  necessary  to  apply  a  plaster- 
dressing,  and  give  a  guarded  prognosis  as  to  the  future  usefulness  of 
the  joint.  If  the  continued  application  of  cold  increases  the  pain, 
make  inunctions  of  mercurial  ointment,  and  apply  moist,  warm  com- 
presses covered  with  gutta-percha  and  wadding. 

A  form  of  injury  peculiar  to  joints  is  distortion  (literally,  twist- 
ing). This  is  an  injury  that  occurs  especially  often  in  the  foot,  and 
which  is  commonly  called  "  turning  the  foot."  Such  a  distortion, 
which  is  possible  in  almost  any  joint,  consists  essentially  in  a  tension, 
too  great  stretching  and  even  partial  rupture,  of  the  capsular  liga- 
ments, with  escape  of  some  blood  into  the  joint  and  surrounding  tis- 
sue. The  injury  may  be  very  i:)ainfLil  at  the  time,  and  its  consequences 
are  not  unfrequently  tedious,  especially  if  the  treatment  be  not 
rightly  conducted.  Usually  abstraction  of  blood  and  cold  are  resorted 
to  in  these  cases  also,  but  with  only  temporary  benefit.  It  is  much 
more  important  to  keep  the  joint  perfectly  motionless  after  such  in- 
juries, so  that,  if  any  of  the  ligaments  be  ruptured,  they  may  heal  and 
acquire  their  previous  firmness.  The  simplest  way  of  attaining  this 
object  is  by  applying  a  firm  dressing,  such  as  the  plaster-bandage, 
with  which  we  may  permit  the  jiatient  to  go  about,  if  it  gives  him  no 
pain.  After  ten,  twelve,  or  fourteen  days,  according  to  the  severity 
of  the  injury,  we  may  remove  the  dressing,  but  renew  it  at  once  if  the 
patient  has  pain  on  walking.  It  may  sometimes  be  necessary  to  Avear 
this  dressing  three  or  four  weeks.  This  appears  a  long  time  for  such 
an  injury ;  but  I  can  assure  you  that,  without  the  application  of  a  firm 
dressing,  the  consequences  of  these  sprains  often  continue  for  months, 
at  the  same  time  the  danger  of  subsequent  chronic  inflammation  of 
the  joint  is  increased.  Hence  you  must  not  promise  too  speedy  a  cure, 
and  must  always  treat  these,  often  apparently  insignificant  injuries, 
conscientiously  and  carefully. 

[Besides  immobilization  an  excellent  remedy  for  the  relief  of 
pain  and  restoration  of  function  after  slight  sprain  is  rubbing  and 
kneading  the  part  immediately  after  the  injury,  a  procedure  used 
by  the  Hindoos  and  Grecians.  This  is  called  massagr,  and  consists 
in  rubbing  the  skin  all  over  the  injured  part,  as  far  as  the  joint 


OPENINGS  OF  THE  JOINTS.  251 

above,  with  oil  or  some  fatty  substance  ;  the  hand  of  the  rubber 
shoukl  also  be  well  greased,  so  as  to  prevent  friction  on  the  skin. 
Then  rub  at  first  lightly,  and  gradually  with  increasing  pressure, 
from  below  upward  toward  the  body,  so  that  the  fingers  applied 
below  the  injured  joint  are  carried  up  to  the  next  joint,  as  if  you 
would  press  a  fluid  from  the  periphery  toward  the  centre  of  circu- 
lation. It  has  been  shown  by  experiment  that  granular  coloring- 
matter  (as  cinnabar,  India-ink,  etc.)  injected  into  the  knee  of  a 
rabbit  may  be  made  to  enter  the  lymphatic  vessels  and  spaces  of 
the  connective  tissue  of  the  thigh  within  a  few  minutes  by  massage. 
The  same  is  true  of  pathological  products,  blood-extravasations,  etc. 

There  is  no  doubt  that  by  massage  we  may  induce  rapid  absorp- 
tion of  blood  and  inflammatory  swelling  ;  the  pain,  at  first  severe, 
disappears  during  the  massage.  The  resolvent  elfects  are  most  de- 
cided in  the  four  or  six  hours  after  the  injury  ;  later,  when  there 
is  acute  inflammation  present,  it  seems  less  reliable,  but  when  the 
acute  inflammatory  swelling  has  passed  it  may  be  tried  more  ener- 
getically. Later  we  shall  treat  of  the  employment  of  this  method 
in  chronic  affections  of  the  joints. 

Unfortunately,  in  spite  of  the  most  careful  treatment,  chronic 
inflammations  often  follow,  which  not  only  prove  tedious  but  in  the 
course  of  years  destroy  the  joint  by  fungous  disease  ;  this  is  es- 
pecially apt  to  occur  in  children  and  feeble  persons  of  scrofulous 
habit.] 

OPENIIQ^GS    OF    THE    JOINTS,    AST)    ACUTE    TRAUMATIC    ARTICULAR 
INFLAMMATIONS. 

In  now  passing  to  wounds  of  the  joint,  we  make  an  immense 
spring  as  regards  the  importance  of  the  injury.  While  a  contusion 
and  sprain  of  the  joint  are  scarcely  noticed  by  many  patients,  the 
opening  of  a  synovial  sac,  with  escape  of  synovia,  even  if  tlie  wound 
be  not  large,  always  has  a  serious  efiiect  on  the  function  of  the  joint, 
and  is  not  unfrequently  dangerous  to  life.  Here,  again,  we  have 
the  difference  between  subcutaneous  traumatic  inflammations  and 
those  which  open  outwardly,  of  which  we  spoke  when  on  the  sub- 
ject of  contusions,  and  which  we  also  saw  in  subcutaneous  and  open 
fractures.  Moreover,  in  the  joints,  we  have  closed  irregularly-shaped 
sacs,  in  which  the  pus,  once  formed,  remains,  and,  besides  inflamma- 
tion of  the  serous  membranes,  may  result  in  very  tedious  processes, 
but  in  its  acute  state  often  has  a  bad  effect  on  the  general  health  of 
the  patient. 

I  think  the  quickest  way  to  describe  the  process  will  be  to  give 
you  a  few  examples.     We  are  here  speaking  only  of  simple  pimc- 


252  INJURIES   OF  THE  JOINTS. 

tured,  incised,  or  cut  wounds,  without  complications  from  sprains 
or  fractures,  and  choose  as  our  example  the  knee-joint ;  at  the  same 
time  we  must  remark  that  injuries  of  this  joint  are  regarded  as  the 
most  severe.  A  man  comes  to  you,  who,  in  cutting  wood,  has  re- 
ceived a  wound  half  an  inch  long,  near  the  patella,  and  which  has 
bled  but  little.  This  may  have  happened  some  hours  before,  or 
even  the  previous  day.  The  patient  pays  little  attention  to  the 
wound,  and  only  asks  your  advice  about  a  proper  dressing.  You 
inspect  the  wound,  find  that  from  its  position  it  corresponds  to  the 
knee-joint,  and  around  it  you  may  perhaps  see  some  serous,  thin, 
mucous,  clear  fluid,  which  escapes  in  greater  quantities  when  the 
joint  is  moved.  This  will  call  your  attention  particularly  to  the 
injury  ;  you  examine  the  patient,  and  learn  from  him  that,  immedi- 
ately after"  the  injury,  there  was  not  much  bleeding,  but  a  fluid  like 
white  of  egg  escaped.  In  such  dases  you  may  be  certain  that  the 
joint  has  been  opened,  otherwise  the  synovia  could  not  have  escaped. 
In  small  joints  the  escape  of  synovia  is  so  slight  as  to  be  scarcely 
noticeable,  hence,  in  injuries  of  the  finger-joint,  and  even  of  the 
ankle,  elbow%  and  wrist,  it  may  for  a  time  be  doubtful  whether  the 
wound  has  penetrated  the  joint  or  not.  [While  a  person  Avith  sim- 
ple fracture  of  the  thigh  is  compelled  by  pain  and  loss  of  function 
to  regard  himself  as  a  patient,  one  with  a  wound  of  the  knee-joint 
may  go  around  wdth  little  difficulty  and  be  unaware  of  the  serious 
nature  of  his  injury.  In  no  class  of  wounds  do  such  serious  results 
come  from  neglect,  and  great  is  the  responsibility  of  the  surgeon 
who  does  not  recognize  the  danger  of  the  case  at  the  start. 

Treatment  will  depend  on  whether  the  wound"  is  very  recent  or 
has  been  exposed  to  the  air.  Examination  should  first  be  made  for 
foreign  bodies,  for  haemorrhage,  and  as  to  the  extent.  If  you  can 
hope  that  there  has  been  no  infection  and  that  little  blood  has  en- 
tered the  joint,  disinfect  the  wound  and  parts  around,  and  try  to 
induce  union  as  rapidly  as  possible,  closing  the  wound  by  deep  su- 
tures ;  then  apply  a  Lister'^s  dressing  and  make  even  compression. 

An  important  point  in  treatment  of  all  wounds  of  joints  is  ab- 
solute rest  ;  this  you  should  ensure  by  proj^er  splints  or  a  plaster 
dressing,  Avhich  should  be  worn  till  the  wound  in  the  soft  parts  has 
closed,  and  the  joint  is  entirely  free  from  inflammation.  Under  this 
treatment  the  wound  may  heal  by  first  intention.  If  the  wound 
has  become  infected,  leeches,  cups,  ice,  etc.,  do  little  good  ;  if  it  has 
not,  they  are  superfluous.  In  the  joint  there  is  usually  an  increase 
of  synovia,  which  causes  swelling  ;  but  the  even  compression  may 
induce  its  rapid  absorption  ;  even  in  a  week  the  joint  may  have  its 
natural  size.     At  first  the  patient  will  have  tension  and  heat  and  be 


OPENINGS  OF   THE   JOINTS.  253 

feverish,  but,  wlien  the  swelling  subsides,  feels  well  and  free  from 
pain.  Even  in  such  cases  it  is  well  to  leave  the  fixed  dressing  on 
for  four  weeks,  or  even  longer,  if  there  is  any  swelling  or  sensitive- 
ness, and  then  to  begin  motion  very  gradually  ;  the  joint  has  become 
stiff  and  the  muscles  atrophied  ;  at  the  first  passive  motions  we 
usually  feel  slight  grating  of  the  articular  surfaces  ;  this  soon  disap- 
pears under  methodical  and  careful  gymnastics  and  massage  ;  in 
addition  you  may  employ  tepid  baths,  cold  douches,  frictions  with 
spirits  of  camphor,  ammonia,  etc.,  and  sometimes  moist  warmth. 
In  favorable  cases  motion  is  soon  perfect. 

But,  if  the  wound  was  infected  at  first,  or  if  there  was  consid- 
erable haemorrhage  into  the  joint,  and  air  has  entered  it,  the  case  is 
entirely  diiferent  ;  even  if  the  wound  of  the  soft  parts  was  insig- 
nificant and  the  edges  had  closed  so  that  the  joint-wound  is  not 
perceived,  for  the  first  two  or  three  days  all  seems  to  go  smoothly, 
the  fourth  or  fifth  day  you  may  find  swelling  of  the  joint,  the  skin 
over  it  is  red  and  hot,  the  sutures  have  cut  into  the  flesli,  and  thin 
pus  escapes  from  the  wound.  The  skin- wound  may  be  superficially 
closed,  and  on  removing  the  sutures  the  edges  gape  and  synovia 
mixed  with  pus  may  flow  from  the  joint.  If  there  has  been  haemor- 
rhage and  entrance  of  air  into  the  joint,  in  the  course  of  twenty- 
four  hours  there  is  usually  intense  local  and  general  reaction,  the 
joint  is  tense  and  painful,  the  patient  feverish  ;  if  you  open  the 
adhesions  the  third  or  fourth  day,  a  dark,  badly-smelling  fluid  com- 
posed of  synovia,  pus,  and  blood-coagula,  escape.  These  are  the 
most  dangerous  cases  ;  if  not  quickly  recognized  and  treated,  there 
is  speedy  decomposition  in  the  joint. 

To  take  an  example  of  a  less  acute  process  :  A  man  has  been 
stuck  in  the  knee  with  a  butcher's  knife,  and  has  had  no  proper 
treatment  ;  he  may  have  limped  around  for  some  days  in  spite  of  the 
pain,  but  toward  the  end  of  the  week  this  becomes  so  severe  that 
the  slightest  motion  or  touch  is  unbearable  ;  the  patient  with  both 
hands  and  the  other  leg  holds  it  quiet  ;  about  the  joint  it  is  red, 
hot,  and  the  knee  and  leg  are  swollen  ;  there  is  fever,  with  evening 
exacerbation,  loss  of  appetite,  and  emaciation.  It  may  be  that 
after  the  escape  of  some  turbid  synovia  the  wound  has  adhered 
again,  or  else  there  is  continued  flow  of  sero-mucus  gradually 
changing  to  pus,  or  else  swelling  and  fluctuation  of  the  joint ;  the 
great  pain,  increased  temperature,  oedema  of  the  thigh,  etc.,  indi- 
cate intense  arthritis.  In  such  cases,  if  the  limb  be  not  fixed,  the 
joint  becomes  flexed  even  to  a  right  angle. 

The  cause  of  this  flexion  of  inflamed  joints  is  probably  that  the 
sensitive  nerves  of  the  synovial  membrane  induce  contraction  of 


254  INJURIES  OF  THE  JOINTS. 

the  flexors  by  reflex  irritation.  The  explanation  that  flexion  oc- 
curred because  joints  hold  most  fluid  when  between  flexion  and  ex- 
tension, has  been  disproved  ;  flexion  may  occur  in  joint  inflamma- 
tions without  collection  of  fluid,  and  is  often  absent  in  chronic, 
painless  dropsy  of  the  jointr.  The  high  pressure  necessary  in 
Bonnefs  experiments  to  induce  flexion  of  the  joint  jjrobably  never 
occurs  in  living  patients.  At  all  events,  observation  teaches  that 
acute  painful  synovitis  is  most  apt  to  cause  flexion,  and  on  the  other 
hand  that  pain  decreases  if,  during  anaesthesia,  the  joint  be  straight- 
ened, and  if  fixed  in  this  position,  pain  gradually  ceases. 

If  proper  treatment  be  not  adopted,  the  fluid  in  the  joint  in- 
creases rapidly  ;  the  tension  is  greater,  pain  unbearable,  till  finally 
the  skin-wound  is  too  small  for  the  escape  of  the  secretion,  the  ar- 
ticular capsule  is  perforated  by  pus  which  escapes  into  the  surround- 
ing tissue.  Spontaneous  cure  may  thus  occur,  the  pus  about  the 
joint  quickly  reaching  the  surface,  and  the  abscess  closing  up  grad- 
ually. In  such  cases  the  final  result  is  tolerably  good  if  the  acute 
synovitis  has  not  caused  too  much  destruction  ;  the  fever  subsides  as 
soon  as  the  pus  escapes,  the  local  symptoms  of  inflammation  mod- 
erate, and  finally  the  perfoi'ations  and  original  wound  heal  ;  but 
stiffness  of  the  joint  may  remain.  If  the  faulty  position  be  not 
rectified,  the  joint  may  become  fixed  in  flexion,  the  ligaments,  ten- 
dons, and  fasciiB  atrophy,  harden,  and  may  impair  the  use  of  the 
limb.  This  result  is  the  more  probable  the  longer  suppuration  con- 
tinues, and  the  deeper  synovitis  has  affected  the  parts. 

But  this  result  is  not  the  most  serious  or  most  frequent.  The 
rule  rather  is  that,  when  suppuration  has  once  attacked  the  joint  and 
has  not  been  properly  treated,  it  steadily  progresses  ;  the  capsule  is 
attacked,  and  in  spite  of  the  open  wound  it  ulcerates,  and  pus  es- 
capes into  the  parts  around  the  joint.  In  such  cases  there  is  usually 
a  deep,  indistinctly  fluctuating  tumor  ;  pressure  upon  v.hich,  even  at 
a  distance  from  the  joint,  evacuates  slowly  through  the  wound  a 
thin  purulent  fluid.  Part  of  the  synovia  may  escape  ^nd  continue 
to  secrete  clear  serum  ;  this  is  particularly  apt  to  occur  in  the  knee, 
part  of  the  capsule  being  shut  off  from  the  rest  by  the  swollen 
membrane,  as  in  the  blind  sac  under  the  tendon  of  the  quadriceps 
and  between  the  patella  and  femur  ;  but,  if  the  whole  cavity  be  at- 
tacked, it  is  just  in  these  spaces  that  pus  is  most  persistently  re- 
tained. 

Even  where  pus  has  not  escaped  into  the  surrounding  tissue, 
abscesses  (periarticular)  may  form  in  the  soft  parts  ;  probably  from 
products  of  inflammation  from  the  joint  being  carried  by  the  lym- 
phatics into  the  periarticular  connective  tissue,  and  there  inducing 


OPENINGS  OF  THE  JOINTS.  255 

inflammation  and  suppuration  ;  latei*,  the  tissue  between  these  ab- 
scesses and  the  joint  may  be  destroyed,  and  communication  be 
established.  In  the  neighboring  sheaths  of  the  tendons  suppura- 
tion creeps  along,  at  various  places  perforations  occur  ;  the  whole 
limb  is  filled  with  pus,  which,  on  pressure,  appears  at  tlie  various 
openings  ;  destruction  of  the  capsule  and  ligaments  renders  the 
limb  abnormally  movable — especially  in  the  hinge-joints  do  we 
notice  lateral  motion  ;  but  the  patient  has  lost  the  power  of  active 
motion  of  the  joint,  the  muscles  are  infiltrated  or  have  suppurated. 
Of  course,  with  such  severe  local  processes,  the  general  condition 
is  much  affected.  From  the  first  the  patient  has  had  fever  ;  with 
evening  exacerbations  to  103°,  loss  of  appetite  and  sleep,  and  con- 
tinued pain  ;  in  three  weeks  he  would  scarcely  be  recognizable.  If 
suppuration  extends  to  the  soft  parts,  sheaths  of  the  tendons,  etc., 
repeated  chills  will  occur,  the  face  is  sunken,  mind  dull,  the  patient 
complains  little,  talks  disjointedly  and  drowses  ;  the  tongue  be- 
comes dry  and  coated,  speaking  and  swallowing  are  interfered  with  ; 
at  night  there  is  delirium  or  restlessness.  Even  in  this  stage  re- 
covery would  be  possible  if  the  suppuration  would  cease,  the  fever 
abate,  and  the  process  become  chronic.  But  this  rarely  happens. 
Patients  are  usually  so  exhausted  that,  even  when  the  local  affec- 
tion takes  a  favorable  turn,  they  die  of  marasmus.  But  most  cases 
die  of  pyaemia  with  pulmonary  abscesses,  or  from  profuse  dysen- 
tery, or  with  encephalitis  and  suppurative  meningitis. 

To  avoid  the  unfavorable  results  of  a  penetrating  wound  of  the 
joint,  you  should  prevent  or  limit  suppuration  and  decomposition 
of  the  discharges.  In  case  of  a  joint-wound  complicated  by  pres- 
ence of  foi-eign  bodies  or  considerable  haemorrhage  in  the  joint,  this 
should  be  opened  freely  by  one  or  two  long  incisions  to  give  free 
access  ;  these  incisions  should  be  in  the  long  axis  of  the  limb,  and 
made  with  as  little  injury  to  the  soft  parts  as  possible.  Formerly 
it  was  not  considered  enough  to  open  the  joint,  a  resection  was 
made  ;  now  this  would  not  be  done  unless  the  ends  of  the  bone 
were  bi-oken,  as  by  a  gunshot-wound,  or  a  partial  resection  might 
be  necessary  to  permit  escape  of  secretions.  After  arresting  the 
haemorrhage,  while  kneading  and  moving  the  joint,  you  wash  it  out 
with  quantities  of  a  two-per-cent.  solution  of  carbolic  acid,  intro- 
duce drainage-tubes,  and  close  the  wound  by  sutures  ;  then  apply 
a  Lister''s  dressing  and  a  splint,  or  permanent  extension.  If  sup- 
puration has  already  begun  when  the  joint  comes  under  treatment, 
or  if  secretions  have  accumulated  in  spite  of  drainage-tubes,  etc., 
Zisfer^s  dressing  will  do  little  good  ;  in  such  cases  try  permanent 
irrigation  with  Buro\o''s  solution,  but  apply  it  very  freely,  and  it 


256  INJURIES   OF  THE  JOINTS. 

had  better  be  done  the  first  time  during  anrestbesia.  Oj^en  tbe  joint 
freely,  and  wherever  there  is  a  pocket  make  an  opening.  Often 
you  will  find  suppurating  granulations  on  the  inner  surface  of  the 
synovial  sac  ;  these  should  be  scraped  off,  then  rub  the  surface 
with  a  di-y,  clean  sponge.  Open  all  collections  of  pus  around  the 
joint,  introducing  a  flexible  probe  into  the  deepest  pockets  and  cut- 
ting down  on  its  point,  of  course  avoiding  lai-ge  vessels,  nerves, 
etc.  ;  these  abscesses  also  may  be  scraped  out.  When  possible, 
Usmarchh  bandage  should  be  previously  applied.  "When  the  cavi- 
ties have  all  been  attended  to,  apj^ly  exact  compression,  to  prevent 
bleeding  when  the  elastic  is  removed,  then  keep  the  limb  elevated 
half  an  hour.  The  dressing  should  be  removed  in  twenty-four 
hours,  when  it  is  usually  so  filled  with  pus  and  blood  that  it  may 
be  removed  without  arousing  haemorrhage  ;  the  gaping  wounds 
should  again  be  washed  out,  drainage-tubes  introduced  when  neces- 
sary, cavities  filled  with  charpie  soaked  in  acetate  of  alumina,  and 
the  limb  covered  with  compresses  wet  with  the  same  ;  the  limb 
should  be  put  in  a  splint,  laid  on  a  rubber  cloth,  two  or  more  drain- 
age-tubes projecting  from  the  dressing  are  connected  with  an  irri- 
gator, and  the  Avhole  complicated  wound  may  thus  be  constantly 
washed  by  a  stream  of  antiseptic  fluid  [Buroir's).  To  secure  the 
entrance  of  di'ainage-tubes  into  the  deep  pockets,  you  may  pass 
through  them  lead  or  iron  wires,  so  you  can  give  them  any  direc- 
tion. If  properly  applied,  permanent  irrigation  may  induce  great 
change  in  the  wound,  even  in  one  day.  It  usually  arrests  at  once 
decomposition  of  pus  ;  the  temperature  falls,  pain  subsides,  the 
quantity  of  pus  decreases  ;  swelling  and  infiltration  about  the  joint 
lessen.  If  the  disease  has  not  gone  so  far  as  to  destroy  the  articu- 
lar ligaments,  the  joint  may  recover  with  normal  motion  ;  to  ensure 
this,  irrigation  should  be  continued  as  long  as  there  is  suppuration. 
If  opening  and  drainage  of  the  joint  was  attended  to  at  first,  we 
may  certainly  expect  perfect  cure. 

In  spite  of  the  above  treatment  of  penetrating  wounds  of  joints, 
which  gives  results  that  a  few  years  since  would  have  appeared 
wonderful,  cases  requiring  amputation  do  sometimes  occur.  If  the 
suppuration  cannot  be  arrested,  or  the  patient  has  not  come  under 
our  care  till  he  had  chills,  suppuration  of  the  soft  parts,  and  con- 
'tinued  fever,  then  the  only  hope  of  saving  the  patient  is  to  ampu- 
tate through  the  sound  tissue.  Even  this  is  often  inefl^ectual,  gen- 
eral purulent  infection  having  already  occurred,  with  metastatic 
abscesses  of  the  internal  organs,  or  the  patient  being  too  much  ex- 
hausted. But  amputation  has  the  advantage  of  removing  at  once 
the  focus  wheuce  the  infection  proceeds.     The  immediate  effect  of 


OPENINGS  OF  THE  JOINTS.  257 

this  operation  is  often  wonderful,  the  temperature,  which  for  weeks 
may  have  been  103°  or  104°,  may  sink  at  once  to  normal,  or  even 
below  ;  the  general  condition  improves,  the  dry,  brown  tongue  be- 
comes moist  and  clean,  appetite  returns,  the  jaatient  sleeps,  delirium 
disappears,  and  in  two  or  three  days  he  may  be  scarcely  recogniz- 
able. The  wound  usually  heals  rapidly,  unless  we  may  have  been 
unable  to  operate  entirely  in  sound  tissue.  Sometimes  apparently 
hopeless  patients  are  saved  by  amputation. 

Modern  treatment  of  penetrating  wounds  of  joints,  as  of  com- 
pound fractures,  has  greatly  changed  the  prognosis,  as  well  as  the 
statistics  ;  not  only  do  many  cases  now  recover  that  formerly  died, 
but  perfect  recovery,  with  free  motion  of  the  joint,  is  almost  the 
rule  in  ordinary  cases.  Formerly  a  penetrating  wound  of  a  joint 
either  led  to  immediate  amputation  or  resection,  or,  if  treated  ex- 
pectantly, and  after  escaping  many  dangers,  the  patient  recovered 
with  a  limb  at  all  useful,  the  result  was  considered  a  triumph  ;  while 
now  it  is  almost  wrong  for  a  case  of  joint- wound  that  comes  under 
treatment  early  not  to  heal  by  first  intention  and  without  danger 
to  life.  Such  favorable  cases  did  occur  before  Jjister^s  method  was 
used,  and  may  now  result  without  treatment,  but  it  is  more  by 
accident  than  due  to  the  surgeon. 

In  speaking  of  traumatic  arthritis  we  have  said  nothing  of  the 
finer  pathological  changes  in  the  inflamed  joint ;  so  let  us  return 
and  examine  the  histological  processes  as  they  have  been  studied 
on  the  dead  body,  on  amputated  limbs,  and  by  experiments  on  ani- 
mals. In  inflamed  joints  the  disease  affects  chiefly,  and  at  first 
exclusively,  the  synovial  membrane  ;  unless  this  has  been  carefully 
dissected,  we  consider  it  much  thinner  than  it  really  is  ;  in  most 
places  it  is  thicker  and  more  succulent  than  pleura  or  peritonaeum, 
and  is  separated  from  the  fibrous  capsule  of  the  joint  by  a  loose, 
subserous,  and  sometimes  very  fat,  layer  of  cellular  tissue,  so  that 
you  can  detach  the  synovial  sac  of  a  knee-joint  to  the  cartilages. 
It  consists  of  connective  tissue,  whose  surface  is  covered  with  pave- 
ment endothelium,  and  near  the  surface  is  a  capillary  network  ; 
according  to  IFueter,  these  membranes  have  no  lymphatic  vessels, 
while  there  are  plenty  in  the  sub-synovial  tisssue.  This  is  surpris- 
ing. Tillmans  confirmed  this  observation  in  rabbits  and  dogs,  but 
in  oxen  found  numerous  lymphatics,  both  in  the  superficial  and  deep 
layers  of  the  synovia. 

The  surface  of  the  synovia  shows,  especially  at  the  sides  of  the 

joint,  numerous  tufts  ;  these  contain  rather  complicated  capillary 

loops.     Synovial  share  with  other  serous  membranes  the  peculiarity 

of  secreting  a  quantity  of  serum  when  irritated  ;  at  the  same  time 

18 


258  INJURIES  OF  THE  JOINTS. 

the  vessels  are  dilated  and  become  tortuous  near  the  surface  ;  the 
membrane  loses  its  smooth,  glistening  look,  and  becomes  dull,  yel- 
lowish, then  reddish  and  velvety.  This  change  is  primarily  due  to 
the  excessive  diapedesis  of  red  blood-corpuscles  which  escape  with 
the  serum  ;  but  subsequently  to  the  numerous  newly-formed  blood- 
vessels which,  looped  and  crowded,  press  to  the  surface,  and  to  the 
fine  tufts,  which  give  the  velvety  look.  In  most  cases  there  is  a 
fibrinous  deposit,  a  so-called  pseudo-membrane  like  that  formed  on 
the  pleura  and  j^eritonaeum. 

Microscopic  examination  of  the  synovial  membrane  in  this  state 
shows  that  its  whole  tissue  is  densely  infiltrated  with  cells,  which 
collect  so  on  the  surface  that  the  tissue  seems  to  consist  of  small 
round  elements,  the  more  superficial  of  which  exactly  resemble  pus- 
corpuscles.  In  the  immediate  vicinity  of  the  distended  vessels  the 
cells  are  particularly  plenty,  Avhich  may  be  due  to  white  blood-cells 
wandering  from  the  vessels  ;  red  corpuscles  also  seem  to  escaj^e. 
The  pseudo-membranes  are  entirely  composed  of  small  round  cells 
united  by  fibi'inous  substance.  The  connective  tissue  of  the  mem- 
brane has  jiartly  lost  its  striation  and  assumed  a  gelatinous  consist- 
ence, so  that  it  greatly  resembles  the  intercellular  substance  of 
granulation  tissue.  The  fluid  of  the  joint  gradually  becomes  turbid 
and  purulent,  and  contains  pus-corpuscles  in  gradually-increasing 
quantities.  Still  later  the  whole  surface  of  the  synovia  becomes  so 
vascular  that  to  the  naked  eye  it  looks  like  a  spongy,  finely-granular 
surface. 

The  condition  of  the  synovial  membrane  at  first  most  resembles 
that  of  mucous  membranes  in  acute  catarrh.  So  long  as  there  is 
merely  superficial  suppuration,  without  softening  of  the  tissue  (ul- 
ceration), the  membrane  may  return  to  the  normal  state  ;  but  if 
pseudo-membranes  have  formed  and  the  parenchyma  is  inflamed  and 
suppurates,  the  only  result  is  formation  of  cicatrix. 

There  may  be  escape  of  j^us  from  the  joint  into  the  subcutaneous 
cellular  tissue,  and  this  is  apt  to  occur  at  special  points  which  are 
predisposed  by  their  anatomical  conformation  ;  but  there  may  also 
be  independent  suppurations  about  the  joint  not  connected  with  it, 
from  reabsorption  of  phlogogenous  matter  from  the  joint.  Peri- 
articular abscesses  come  either  with  acute  or  chronic  abscesses  from 
the  same  cause,  reabsorption  of  irritant  matter  ;  this  is  also  seen 
exceptionally  in  adjacent  lymphatic  glands,  which  swell,  become 
painful,  and  exceptionally  suppurate  ;  there  may  also  be  lymphan- 
gitis. Cartilage  does  not  participate  till  late  in  the  process  ;  its  sur- 
face becomes  cloudy,  and  if  the  process  be  very  acute  it  disinte- 
grates into  molecules  or  large  portions  become  necrosed  ;  it  becomes 


OPENINGS  OF  THE  JOINTS.  259 

detached  from  the  bone  by  suppuration  going  on  between  them  ; 
the  changes  in  the  cartilage  are  chiefly  passive,  a  sort  of  maceration 
such  as  occurs  in  the  cornea  in  severe  blenorrhoea  or  diphtheria. 
There  are  scarcely  any  two  parts  of  the  body  presenting  such  anal- 
ogy as  the  conjunctiva  in  its  relation  to  the  cornea  and  the  synovial 
membrane  in  its  relation  to  the  cartilage.] 


260  INJURIES  OF  THE  JOINTS. 


LECTURE   XVIII. 

Simple  Dislocations ;  Traumatic,  Congenital,  Pathological  Luxations,  Subluxations.— 
Etiology. — Difficulties  in  Eeduction,  Treatment;  Eeduction,  After-Treatment.— 
Habitual  Luxations. — Old  Luxations,  Treatment. — Complicated  Luxations. — Con- 
genital Luxations. 

SIMPLE  DISLOCATIONS. 

By  a  dislocation  (luxatio),  we  understand  that  condition  of  a 
joint  in  which  the  two  articular  ends  are  entirely,  or  for  the  most  part, 
thrown  out  of  their  mutual  relations,  the  articular  capsule  being  gen- 
eraUj  partly  ruptvu-ed  at  the  same  time  ;  at  least,  tliis  is  almost  always 
the  case  in  traumatic  luxations,  i.  e.,  in  those  that  have  occurred  in  a 
healthy  joint  as  a  result  of  the  apphcation  of  force.  Besides  these,  we 
distinguish  congenital,  and  spontaneous  or  imthological  luxations. 
The  latter  result  from  gradual  ulcerative  destruction  of  the  articular 
extremities  and  ligaments,  since  there  is  no  longer  the  natural  oppo- 
sition to  muscular  contraction  ;  we  shall  speak  of  this  hereafter,  as  it 
essentially  belongs  among  the  results  of  certain  diseases  of  the  joints. 
At  the  end  of  this  section  we  shall  say  something  about  congenital 
luxations.  At  present  we  shall  speak  only  of  traumatic  dislocations. 
We  occasionally  hear  also  of  subluxations  /  by  this  expression  we 
imply  that  the  articular  surfaces  have  not  separated  entirely,  so  that 
the  luxation  is  incomjjlete.  By  complicated  luxations  we  mean  those 
accompanied  by  fractures  of  bones,  wounds  of  the  skin,  or  ruptures  of 
large  vessels,  or  nerves,  or  all  of  these.  You  must  also  observe  that 
it  is  customary  to  designate  the  lower  part  of  the  limb  as  the  part 
luxated ;  as  for  instance  at  the  shoulder-joint,  not  to  speak  of  a  lux- 
ated scapula,  but  of  dislocation  of  the  humerus ;  at  the  knee-joint,  not 
of  luxation  of  the  femur,  but  of  the  tibia,  etc. 

Dislocations  generally  are  rare  injuries ;  in  some  joints  they  are  so 
rare  that  the  whole  number  of  cases  knoAvn  is  scarcely  half  a  dozen. 
It  is  said  that  fractures  are  eight  times  as  frequent  as  dislocations ;  it 
seems  to  me  that  even  this  is  too  large  a  proportion  for  dislocations. 
The  distribution  of  luxations  among  the  different  joints  varies  very 
greatly ;  let  me  show  you  this  by  some  figures :  According  to  Mai- 
gaign^s  statistics,  among  489  dislocations  there  were  8  of  the  trunk, 
62  of  the  lower  and  419  of  the  upper  extremity,  and  among  the  lat- 
ter there  were  321  of  the  shoulder.  Hence  you  see  that  the  shoulder 
is  a  very  favorite  joint  for  dislocations,  which  is  readily  explained  by 
its  construction  and  free  mobility.  Dislocations  are  more  frequent 
among  men  than  women,  for  the  same  reasons  that  we  have  alreadv 
shown  fractures  to  be  more  frequent  in  men. 


DISLOCATIONS.  261 

As  inducing  causes  for  dislocations,  we  have  external  applications 
of  force  and  muscular  action  ;  the  latter  are  rare,  but  cases  have  been 
observed  where  dislocations  were  caused,  in  epileptics,  for  instance,  by 
muscular  contractions.  As  in  fractures,  the  external  causes  are  divided 
into  direct  and  indirect.  For  instance,  if  one  gets  a  luxation  by 
falling  on  the  shoulder,  it  is  due  to  direct  force;  the  same  luxation 
might  occur  indirectly  by  a  person  with  outstretched  arm  falling  on 
the  hand  and  elbow.  Whether  a  dislocation  or  a  fracture  will  result, 
depends  chiefly  on  the  position  of  the  joint  and  the  nature  of  the 
cause ;  but  much  also  depends  on  whether  the  bones  or  the  articular 
Ugaments  give  way  the  more  readily  ;  for  instance,  by  the  same  manoeu- 
vre on  different  dead  bodies  we  may  sometimes  cause  fracture,  some- 
times dislocation.  As  in  fractures,  there  are  numerous  symptoms  of 
luxation,  of  which  some  may  be  very  noticeable,  and  are  the  more  so 
the  sooner  we  see  the  case,  and  the  less  the  displacement  of  the  ar- 
ticular ends  is  hidden  by  inflammatory  swelling  of  the  superjacent 
soft  parts.  The  altered  form  of  the  joint  is  one  of  the  most  important 
and  striking  symptoms,  but  which  only  leads  quickly  and  certainly  to 
a  diagnosis  when  the  eye  has  been  accustomed  to  readily  recognize 
differences  from  the  normal  form.  Correct  measurement  with  the  eye, 
accurate  knowledge  of  the  normal  form,  in  short,  some  taste  for  sculp- 
ture and  sculptural  anatomy,  so-called  artistic  anaton^y,  are  here  very 
useful.  If  there  is  very  slight  change  of  form,  even  the  most  prac- 
tised will  not  be  able  to  dispense  with  a  comparison  with  the  opposite 
side,  and  hence  I  earnestly  urge  you,  if  you  would  avoid  error,  always 
to  expose  the  upper  or  lower  half  of  the  body,  as  the  case  may  be, 
and  to  compare  the  two  sides.  You  may  best  follow  with  the  eye 
the  direction  of  the  apparently  displaced  bone,  and  if  this  line  does 
not  strike  the  articular  cavity  accurately,  there  will  most  probably  be 
a  dislocation,  if  there  be  not  a  fracture,  close  beloAv  the  articulating 
head  of  the  bone,  which  must  be  determined  by  manual  examination. 
The  lengthening  or  shortening  of  a  limb,  its  position  to  the  trunk, 
the  distance  of  certain  prominent  points  of  the  skeleton  from  each 
other,  often  aid  us  in  making  at  least  a  probable  diagnosis  very 
quickly.  Another  symptom  perceptible  to  the  sight  is  ecch;yTnosis  of 
the  soft  parts,  or  suggillation.  This  is  rarely  distinct  at  first,  because 
the  blood,  escaping  from  the  torn  capsule  only  gradually,  perhaps  not 
for  several  days,  rises  near  the  skin  and  becomes  visible  ;  in  some 
cases  the  effusion  of  blood  is  so  inconsiderable  that  it  is  not  perceived. 
The  symptoms  given  by  the  patient  are,  pain  and  inability  to  move  the 
limb  normally.  The  pain  is  never  so  great  as  in  fractures,  and  only 
appears  on  attempting  to  move  the  limb.  In  some  cases,  patients 
\dth  luxations  may  perform  some  motions  with  the  limb,  but  only  in 


262  INJURIES   OF  THE  JOINTS. 

certain  directions,  and  to  a  very  limited  extent.  Manual  examinaUon 
must  finall}^  settle  the  question  in  most  cases  ;  it  must  show  that  the 
articular  cavity  is  empty,  and  that  the  head  of  the  bone  is  at  some 
other  point,  at  one  side,  above  or  below.  If  the  soft  parts  be  consid- 
erably swollen,  this  examination  may  be  quite  difficult,  and  the  aid 
of  anaesthesia  is  often  necessary  for  a  correct  diagnosis,  especially  if 
the  exhibitions  of  pain  and  the  motions  of  the  patient  interfere.  On 
moving  the  extremity,  which  we  find  springy  or  slightly  movable, 
there  is  occasionally  a  feehng  of  friction,  an  indistinct,  soft  crepitation. 
This  may  result  partly  from  rubbing  of  the  head  of  the  bone  on  torn 
capsular  Hgaments  and  tendons,  partly  from  the  compression  of  firm 
blood-coagula.  Hence,  in  such  varieties  of  crepitation,  we  should  not 
at  once  conclude  on  a  fracture,  but  be  urged  to  more  careful  examina- 
tion. Fractures  of  certain  parts  of  the  articular  ends,  with  disloca- 
tion, are  most  readily  mistaken  for  luxations.  And  formerly  the  mode 
of  expression  on  this  point  was  not  exact,  for  displacements  about 
the  joint,  combined  with  fractures,  and  caused  entirely  by  them,  were 
also  termed  luxations.  At  present  we  distinguish  these  fractures 
within  the  joint,  with  dislocations,  more  sharply  from  luxations 
proper. 

Should  you  be  in  doubt  as  to  whether  the  case  is  one  of  dislocated 
articular  fracture  or  of  luxation,  you  may  easily  decide  the  question 
by  an  attempt  at  reduction.  If  such  a  dislocation  is  readily  reduced 
by  moderate  traction,  but  at  once  returns  Avhen  you  leave  off  the 
traction,  it  is  a  case  of  fracture ;  for  a  certain  art  is  necessary  to  the 
reduction  of  a  dislocation,  and,  when  once  reduced,  it  does  not  readily 
recur,  although  there  are  exceptions  to  this  rule. 

A  contusion  and  sprain  of  the  joint  may  also  be  mistaken  for  lux- 
ation, but  this  error  may  be  avoided  by  careful  examination.  Old 
traumatic  luxations  may  sometimes  be  mistaken  for  dislocations  caused 
by  contraction.  Lastly,  in  paralyzed  limbs,  where  there  is  at  the 
same  time  relaxation  of  the  articular  capsule,  the  joint  may  be  so  very 
movable  that  in  certain  positions  it  will  look  as  if  dislocated.  In 
these  cases,  also,  the  history  of  the  case  and  careful  local  examination 
will  lead  us  to  a  correct  conclusion. 

Regarding  the  state  of  the  injured  parts  immediately  after  the  in- 
jury, in  cases  where  there  has  been  a  chance  to  examine  them,  it  has 
been  fotmd  that  the  capsule  of  the  joint  and  the  synovial  membrane 
are  torn.  The  capsular  opening  is  of  variable  size  ;  occasionally  it  is 
a  slit  like  a  button-hole,  sometimes  it  is  triangular,  \\dth  more  or  less 
ragged  edges ;  ruptures  of  muscles  and  tendons  immediately  around 
the  joint  have  also  been  observed.  The  contusion  of  the  parts  varies 
greatly,  as  does  also  the  effusion  of  blood.     The  head  of  the  bone  does 


REDUCTION   OF   DISLOCATIONS.  263 

not  always  remain  at  the  point  where  it  escapes  from  the  mpttired 
capsule,  but  in  many  cases  it  is  higher,  lower,  or  to  one  side,  as  the 
muscles  attached  to  it  contract  and  displace  it.  It  is  important  to 
know  that  we  must  frequently  bring  the  luxated  head  of  the  bono  into 
a  different  position  before  we  can  carry  it  back  through  the  opening 
in  the  capsule  into  the  articular  cavity. 

Occasionally,  by  some  accidental  muscular  action,  the  dislocation 
is  spontaneously  reduced.  In  the  shoulder,  especially,  this  has  been 
observed  several  times.  But  such  spontaneous  reductions  are  very 
rare,  because  there  are  usually  certain  mechanical  obstructions  to  the 
reduction,  which  must  be  overcome  by  skilful  manipulation.  These 
hinderances  consist  partly  in  contraction  of  the  muscles,  by  which  the 
head  of  the  bone  may  be  caught  between  two  contracted  muscles  ; 
another  far  more  frequent  obstacle  is  a  small  capsular  opening,  or  its 
occlusion  by  the  entrance  of  the  soft  parts.  Lastly,  certain  tensions 
of  the  capsular  or  strengthening  ligaments  may  hinder  the  reposition 
of  recent  traumatic  luxations. 

In  treating  a  luxation  it  must  first  be  skilfully  reduced,  and  then 
means  be  emj)lo3'ed  for  restoring  the  fimction  of  the  injured  limb. 
We  shall  here  only  speak  of  the  reduction  of  recent  dislocations,  by 
which  we  mean  those  that  are  at  most  eight  days  old.  The  most 
favorable  time  for  reducing  a  dislocation  is  immediately  after  the  in- 
jury ;  then  Ave  have  the  least  swelling  of  the  soft  parts,  and  little  or 
no  displacement  of  the  luxated  head  of  the  bone ;  the  patient  is  still 
mentally  and  physically  relaxed  from  the  accident,  so  that  the  reposi- 
tion is  not  unfrequently  very  easy ;  later,  we  shall  often  have  to  facili- 
tate the  operation  by  resorting  to  anaesthetics  to  remove  the  opposition 
of  the  muscles.  Regarding  the  proper  manoeuvres  for  the  reduction, 
we  can  say  but  little  in  general  terms,  for  this  of  course  depends  en- 
tirely on  the  mechanism  of  the  different  joints.  Formerly,  it  was  a 
general  rule,  for  the  reduction  of  dislocations,  that  the  limb  should  be 
brought  into  the  position  in  which  it  was  at  the  moment  of  the  dislo- 
cation, so  that  by  traction  the  head  of  the  bone  might  be  replaced  as 
it  had  escaped.  This  rule  is  only  important  in  a  few  cases ;  at  present, 
in  the  different  dislocations  we  are  more  apt  to  resort  to  very  different 
motions,  such  as  flexion,  hyper-extension,  abduction,  adduction,  eleva- 
tion, etc.  Usually,  the  surgeon  directs  the  assistants  to  make  these 
motions,  and  himself  pushes  the  head  of  the  bone  into  place  when  it 
has  been  brought  before  the  articular  cavity. 

Frequently  the  surgeon  alone  can  accomplish  the  reduction.  I 
have  often  thus  reduced  a  dislocation  of  the  thigh  over  which  various 
colleagues,  aided  by  muscular  laborers,  had  worked  in  vain  for  hours. 
In  these  cases,  every  thing  depends  on  correct  anatomical  knowledge, 


264  INJURIES  OF  THE  JOINTS. 

and  you  may  readily  understand  that  in  a  certain  direction  you  may 
not  unfrequently  slip  the  head  of  the  bone  into  place  with  very  little 
force,  while  in  another  position  it  might  be  entirely  impossible.  When 
the  head  of  the  bone  enters  the  articular  cavity,  it  occasionally  causes 
a  perceptible  snap;  but  this  does  not  always  occur;  we  are  only  per- 
fectly assured  of  successful  reposition  by  the  restoration  of  normal 
mobility. 

If  we  do  not  succeed  alone,  or  with  a  few  assistants,  we  have 
various  aids,  by  applying  long  slings  to  the  limb,  and  having  several 
assistants  draw  in  one  direction.  This  traction,  which  of  course  must 
be  opposed  by  a  counter-extension  of  the  body,  must  be  regular,  not 
by  starts.  If  we  do  not  succeed,  even  in  this  way,  we  call  in  the  aid 
of  machinery  to  increase  the  power.  For  this  purpose  various  instru- 
ments were  formerly  employed,  such  as  the  lever,  screw,  ladders,  etc. 
Now  the  multiplying  pulleys,  or  Schneider-MeneV s  extension-appara- 
tus, is  almost  exclusively  used.  The  multiplying  pulleys,  an  instru- 
ment that  you  already  know  from  your  studies  in  physics,  for  increas- 
ing power,  and  which  is  greatly  resorted  to  in  mechanics,  are  used  as 
follows  :  One  end  of  the  rope  is  fastened  to  a  strong  hook  in  the  wall, 
while  the  other  is  applied  to  the  limb  by  straps  and  buckles.  Counter- 
extension  is  made  on  the  body  of  the  patient,  so  that  it  shall  not 
be  moved  by  the  extension.  An  assistant  draws  on  the  pullej^s, 
whose  power  of  course  increases  with  the  number  of  rollers  emjjloyed. 
Schneider-MeneV s  apparatus  consists  of  a  strong  gallows,  to  the  inner 
side  of  one  post  of  Avhich  is  attached  a  movable  windlass,  wdiich  may 
be  turned  by  a  handle  and  held  by  a  toothed  wheel ;  over  this  wind- 
lass runs  a  strap  which  is  attached  by  a  hook  to  a  bandage  applied 
around  the  luxated  extremity.  In  luxation  of  the  lower  extremity  the 
patient  lies  on  a  table  placed  lengthwise  between  the  posts  of  the  gal- 
lows, or  for  reduction  of  an  arm  he  may  be  seated  on  a  chair  placed 
the  same  way ;  the  counter-extension  is  made  by  straps  by  which  the 
patient  is  fastened  to  the  other  post  of  the  gallows.  Both  of  these 
apparatuses  have  certain  advantages,  but  both  are  troublesome  to  ap- 
ply. In  your  practice  you  will  have  little  to  do  with  them,  as  they 
are  almost  exclusively  employed  in  old  dislocations  whose  treatment 
is  more  rarely  undertaken  in  private  practice  than  in  hospitals  and 
surgical  clinics. 

At  present,  when  we  undertake  this  forcible  reduction,  it  is  always 
under  the  influence  of  anaesthetics.  To  produce  complete  relaxation 
this  anesthesia  must  be  very  profound,  and,  as  the  chest  is  often  cov- 
ered with  straps  and  girdles  for  counter-extension,  the  anassthetic 
must  be  very  carefully  employed  to  avoid  dangerous  results.  But 
there  are  also  other  dangers  which  were  known  to  the  older  surgeons, 


REDUCTION  OF  DISLOCATIONS.  265 

R'ho  did  iiot  u :e  chloroform.  These  are  as  follows:  If  the  patient  is 
tried  too  long  with  these  powerful  remedies,  he  may  suddenly  collapse 
and  die ;  moreover,  the  limb  may  become  gangrenous  from  the  jDress- 
ure  of  the  straps,  or  there  may  be  subcutaneous  rupture  of  large  nerves 
and  vessels,  and  consequent  paralysis,  traumatic  aneurism,  extensive 
suppuration,  and  other  dangerous  local  accidents.  The  results  of 
pressure  from  the  appliances  may  best  be  avoided  by  applying  a  moist 
roller-bandage  from  below  upward,  and  fastening  the  straps  over  this. 
Since  a  regular  pressure  is  thus  made  over  the  entire  limb,  the  press- 
ure of  the  appliance  close  above  the  joint  does  not  prove  so  injm-ious. 
The  time  dm-ing  which  we  may  continue  these  forcible  attempts  at 
replacement  should  be  at  most  half  an  hour ;  if  we  do  not  succeed  in 
this  time,  we  may  be  pretty  certain  of  not  doing  so  at  all.  If  we 
wish  to  try  further  in  such  cases,  we  shovild  resort  to  some  other 
method.  Until  recently,  we  had  no  measure  of  the  force  that  could 
be  used  without  danger,  and  had  to  content  ourselves  with  estimating 
it.  It  seems  scarcely  possible,  by  the  above  means,  to  tear  out  an 
arm  or  a  leg ;  but  not  long  since  this  did  occur  in  Paris,  and  in  a  case 
where  only  manual  extension  was  employed  !  Generally,  the  straps 
tear  sooner,  or  the  buckles  bend.  Subcutaneous  ruptures  of  the  nerves 
and  vessels  would  scarcely  be  caused  in  a  healthy  arm  by  regular  trac- 
titm  on  the  whole  extremity ;  but  they  may  tear,  when  adherent  to 
deep  cicatrices,  and  are  so  atrojDliied  as  to  have  lost  their  normal  elas- 
ticity. If,  under  such  circumstances,  the  conditions  could  always  be 
accurately  appreciated  beforehand,  we  should  frequently  entirely  ab- 
stain from  attempts  at  reduction ;  for,  in  such  cases,  rupture  of  a  nerve 
or  vessel  may  follow  attempts  at  reposition  with  the  hand,  and  we 
cannot  refer  the  accident  to  the  machinery.  An  instrument  has  been 
invented,  by  whose  aid  the  force  employed  in  extension  may  be  meas- 
ured. This  instrument  should  be  inserted  in  the  extension-apparatus, 
and  shows  the  force  employed  in  weight,  as  is  customary  in  physics. 
According  to  31algaigne,  we  should  not  go  above  two  hundred  kilo- 
grammes with  this  dynamometer;  but  such  directions  are  of  course 
only  approximative. 

If  the  reduction  has  been  accomplished,  the  main  point  has  cer- 
tainly been  gained,  but  some  time  is  still  required  for  full  return  of 
the  function  of  the  limb.  The  wound  in  the  capsule  must  heal,  for 
which  purpose  perfect  rest  of  the  joint  for  a  longer  or  shorter  time  is 
requisite.  After  reposition  there  is  always  moderate  inflammation  of 
the  synovial  m.embrane,  wuth  a  slight  effusion  of  fluid  into  the  joint, 
and  the  latter  remains  for  a  time  painful,  stiff,  and  unwieldy.  If  re- 
duction has  closely  followed  the  injury,  the  joint  must  first  be  kept  per- 


266  INJURIES  OF  THE  JOINTS. 

fectly  quiet ;  it  is  surrounded  with  moist  bandages,  and  cold  compresses 
are  applied ;  the  swelling  is  rarely  so  great  as  to  demand  other  anti- 
phlogistic remedies.  In  the  shoulder-joint  after  ten  to  fourteen  days  we 
begin  passive  motion  and  continue  it  till  active  movements  can  be 
made  and  the  arm  is  fully  useful ;  frequently,  it  is  many  months  before 
movements  are  quite  free,  and  elevating  the  arm  is  the  last  motion  to 
return.  In  other  joints  that  have  less  mobility,  active  movements 
may  be  permitted  much  sooner ;  thus  they  are  restored  especially  early 
in  the  elbow  and  hip-joints,  and  in  the  latter  joints  we  may  permit 
attempts  at  motion  the  earlier,  because  there  luxations  do  not  so 
readily  recur. 

If  active  motions  be  permitted  too  soon  after  reduction  of  a  dis- 
location, especially  in  those  joints  where  dislocation  readily  recvu's,  as 
in  the  shoulder  and  lower  jaw,  and  if  the  luxation  recurs  once  or  sev- 
eral times  before  the  capsular  opening  has  healed,  occasionally  the 
capsule  does  not  heal  comjDletely,  or  there  is  so  much  distensibility  of 
the  capsular  cicatrix  that  the  patient  only  has  to  make  a  careless 
motion  to  luxate  the  part  again.  Then  Ave  have  the  state  called 
habitual  luxation^  a  very  annoying  state,  especially  in  the  lower  jaw. 
I  knew  a  woman  who  had  a  dislocation  of  the  jaw  and  did  not  take 
care  of  herself  long  enough  afterward,  so  that  it  soon  returned  and 
had  to  be  reduced  again  ;  the  capsule  was  so  much  stretched  that,  if, 
in  eating,  she  took  too  large  a  morsel  of  food  between  the  back  teeth, 
she  at  once  luxated  the  jaw  ;  she  accustomed  herself  to  the  manoeuvre 
of  slipping  it  into  place,  so  that  she  could  do  it  with  the  greatest 
facility.  Such  an  habitual  luxation  of  the  shoulder  may  occur  in  the 
same  way.  I  have  seen  a  young  man,  who,  when  gesticulating  vio- 
lently, had  carefully  to  avoid  raising  his  arm  quickly,  as  he  almost 
alwaj's  dislocated  it  by  this  motion ;  such  a  state  is  very  annoying, 
and  is  difficult  to  cure ;  recovery  would  only  be  possible  by  long 
rest  of  the  joint,  but  patients  rarely  have  inclination  or  patience  for 
this  treatment.  It  is  well  for  such  patients  to  wear  a  bandage  that 
will  prevent  lifting  or  throwing  back  the  arm  too  mucli ;  if  the  luxa- 
tion be  avoided  for  a  few  years,  it  will  not  recur  so  readily. 

If  a  simple  dislocation  be  not  recognized  and  reduced,  or  if,  for 
various  reasons,  we  cannot  reduce  it,  a  certain  amount  of  mobilit}^  is 
nevertheless  restored,  which  may  be  considerably  increased  by  regu- 
lar use.  From  the  relation  of  the  head  of  the  bone  to  adjacent  bony 
processes,  and  from  displacement  of  muscles,  it  may  be  readily  under- 
stood that,  for  purely  mechanical  reasons,  certain  motions  will  be  im- 
possible, while  others  may  approximate  the  normal  mobility.  But, 
if  the  movements  be  not  methodically  restored,  the  hmb  remains  stiff, 
the  muscles  become  atrophied,  and  the  Umb  is  of  little  use.     The 


CHANGES   IN   OLD   LUXATIONS.  267 

anatomical  changes  in  the  joint  and  parts  around  are  as  follows  :  the 
extravasated  blood  is  reabsorbed;  the  capsule  folds  together  and 
atrophies ;  the  head  of  the  bone  rests  against  some  bone  in  the  vicin- 
ity of  the  articulating  cavity  ;  for  instance,  in  luxation  of  the  humerus 
inward  against  the  ribs  under  the  pectoralis  major,  the  soft  parts 
about  the  dislocated  head  become  infiltrated  with  plastic  lymph  and 
transform  to  cicatricial  connective  tissue,  which  partly  ossifies,  so 
that  a  sort  of  bony  articular  cavity  again  forms,  while  the  head  is 
surrounded  by  a  newly-formed  connective-tissue  capsule.  In  the 
cartilage  of  the  head  of  the  bone,  the  following  changes  visible  to  the 
naked  eye  occur :  the  cartilage  becomes  rough,  fibrous,  and  grows 
adherent  to  the  parts  on  which  it  lies,  by  a  cicatricial,  firm  connective 
tissue.  In  the  course  of  time  this  adhesion  becomes  very  firm,  espe- 
cially if  not  disturbed  by  movements.  The  metamorphosis  of  cartilage 
to  connective  tissue,  followed  microscopically,  takes  place  as  follows  : 
the  cartilage-tissue  divides  directly  into  fine  filaments,  so  that  the 
tissue  acquires  first  the  appearance  of  fibrous  cartilage,  then  of  ordi- 
nary cicatricial  connective  tissue,  which  unites  with  the  parts  around 
and  receives  vessels  from  them.  The  surrounding  muscles,  as  far  as 
they  are  not  torn,  lose  a  large  part  of  their  filaments,  partly  from 
molecular  disintegration,  partly  from  fatty  metamorphosis  of  the  con- 
tractile substance ;  subsequently,  new  muscular  filaments  form  in 
these  muscular  cicatrices. 

This  is  what  we  call  an  old  luxation,  and  it  is  in  such  cases  espe- 
cially that  the  above  methods  of  forcible  reduction  are  employed. 
The  question,  how  long  a  luxation  must  have  existed  before  its  repo- 
sition is  to  be  considered  impossible,  cannot  be  answered  since  the 
introduction  of  chloroform,  and  is  to  be  differently  answered  for  the 
various  joints.  Thus,  dislocations  of  the  shoulder  may  be  reduced  after 
existing  for  years,  while  those  of  the  hip-joint  two  or  three  months 
old  are  reduced  with  difficulty.  The  chief  obstacle  lies  in  the  firm 
adhesions  of  the  head  of  the  bone  in  its  new  position,  and  in  the  loss 
of  contractility  of  the  muscles,  and  their  degeneration  to  connective 
tissue.  Another  question  is,  whether,  when  such  old  dislocations  are 
reduced,  we  attain  the  desired  effect  on  the  function,  especially  in  the 
shoulder.  Imagine  that  the  small  articulating  cavity  is  filled  by  the 
atrophied  capsule,  and  that  the  head  of  the  bone  has  lost  its  cartilage, 
then,  even  if  we  succeed  in  bringing  the  head  to  its  normal  position, 
restoration  of  function  may  still  be  impossible,  and  I  can  assure  you, 
from  my  own  experience,  that  the  final  result  of  a  very  tiresome  and 
long  after-treatment  in  such  cases  does  not  always  repay  the  patience 
and  perseverance  of  the  patient  and  surgeon.  In  such  cases,  the  result 
will  scarcely  be  more  favorable  than  if  the  patient  tries,  by  methodical 


268  INJURIES   OF   THE   JOINTS. 

exercise,  to  make  his  limb  as  useful  as  possible  in  its  new  position, 
which  it  may  have  occupied  for  months  or  years.  We  may  facilitate 
this  exercise  by  breaking-  up  the  adhesions  about  the  head  of  the  bone, 
b}'  rotating  it  forcibly  while  the  patient  is  anjBSthetized.  If,  as  occa- 
sionally happens  in  shoulder-dislocations,  the  head  of  the  bone  in  its 
abnormal  position  so  presses  on  the  brachial  plexus  as  to  cause  paraly- 
sis of  the  arm,  if  reduction  be  impossible,  it  may  be  advisable  to  make 
an  incision  down  to  the  head  of  the  bone  to  dissect  it  out  and  saw  it 
off,  i.  e.,  to  make  a  regular  resection  of  the  head  of  the  humerus.  I 
have  seen  a  case  where,  in  complete  paralysis  of  the  arm  after  a  luxa- 
tion of  the  humerus  downward  and  inward,  decided  improvement  of 
the  function  of  the  arm  was  attained  by  the  above  operation,  although 
there  was  not  complete  recovery  of  the  paralysis. 


COMPLICATED  DISLOCATIONS. 

A  dislocation  may  be  complicated  in  various  ways ;  most  fre- 
quently with  partial  or  entire  fracture  of  the  head  of  the  bone,  which 
is  difficult  to  cure,  and  in  which  reposition  is  often  only  partly  suc- 
cessful ;  in  treatment,  attention  must  alwaj'S  be  paid  to  the  fracture ; 
i.  e.,  a  dressing  must  be  worn  till  the  fracture  has  united.  At  the 
same  time  it  is  advisable  to  renew  the  dressing  frequently,  say  every 
week,  and  to  apply  it  in  a  different  position  each  time,  so  that  the 
joint  may  not  become  stiff.  Nevertheless,  we  cannot  always  succeed 
in  attaining  perfect  mobility,  so  that  I  can  only  advise  you  in  your 
practice  always  to  give  a  doubtful  prognosis  in  such  cases. 

Another  complication  is  a  coincident  wound  of  the  joint.  For 
instance,  the  broad  articular  surface  of  the  lower  epiphysis  of  the 
humerus  or  of  the  radius  may  be  driven  out  of  tlie  joint  with  such 
force  as  to  tear  through  the  soft  parts  and  skin,  and  lie  exposed. 

Of  course  the  diagnosis  is  easy  in  such  cases  ;  rejDosition  is  accom- 
plished according  to  the  above  rules,  but  we  still  have  a  Avound  of  the 
joint ;  and  we  are  liable  to  all  the  chances  spoken  of  under  wounds 
of  joints,  so  that  for  the  prognosis,  the  varieties  of  the  possible  results 
and  the  treatment,  I  refer  you  to  what  has  already  been  said  (p.  224). 
Of  course,  it  is  worse  when  there  is  an  open  fracture  through  the  joint ; 
here  we  can  neither  expect  rapid  closure  of  the  wound  nor  restoration 
of  the  function  of  the  joint,  and  we  run  all  the  dangers  that  threaten 
complicated  open  fractures  and  wounds  of  joints.  The  decision  as  to 
what  must  be  done  in  such  cases  is  easy,  when  there  is  at  the  same 
time  considerable  crushing  or  tearing  of  the  soft  parts ;  under  such 
circumstances,  primary  amputation  must  be  done.     If  the  iniurv  of 


CONGENITAL  LUXATIONS.  269 

the  soft  parts  be  not  great,  we  may  sometimes  hoj)e  for  a  cure  by 
suppuration,  with  a  subsequent  stiff  joint ;  but,  as  experience  shows, 
this  is  always  a  dangerous  experiment.  According  to  the  principles 
of  modern  surgery,  in  such  cases  we  avoid  amputation  by  dissecting 
out  and  sawing  off  the  fractui-ed  articular  ends  of  the  bones  so  as  to 
make  a  simple  wound.  This  is  the  regular  total  resection  of  a  joint, 
an  operation  concerning  which  very  extensive  observations  have  been 
made  during  the  last  twenty  years,  and  of  which  modern  times  is 
justly  proud ;  by  its  means  many  limbs  have  been  preserved,  which, 
according  to  the  old  rules  of  surgery,  should  unhesitatingly  have  been 
amputated. 

In  regard  to  their  danger,  these  resections  vary  greatly  according 
to  the  joint  on  which  they  are  made,  so  that  it  is  difficult  to  make  any 
general  remarks  about  them.  But,  in  a  subsequent  section  (in  the 
treatment  of  chronic  fungous  diseases  of  the  joints),  we  shall  study 
this  very  important  point  more  carefully ;  what  has  been  said  will  give 
you  a  general  idea  of  a  resection  of  the  joint. 


CONGENITAL  LUXATIONS. 

Congenital  luxations  are  rare,  and  we  must  distinguish  them  from 
luxationes  inter  partum  acquisitce,  i.  e.,  those  that  have  resulted  at 
birth  from  manoeuvres  in  extracting  the  child,  and  which  are  merely 
simple  traumatic  luxations  which  may  be  reduced  and  cvu-ed.  Al- 
though congenital  luxations  have  been  observed  in  most  of  the  joints 
of  the  extremities,  they  are  particularly  frequent  in  the  thigh,  and  not 
unfrequently  occur  on  both  sides  at  the  same  time.  The  head  of  the 
bone  stands  somewhat  above  and  behind  the  acetabulum,  but  in  many 
cases  it  can  readily  be  replaced.  As  a  rule,  the  disease  is  first  noticed 
when  the  child  begins  to  walk.  The  most  noticeable  symptom  is  a 
peculiar  wabbling  gait,  which  is  caused  by  the  head  of  the  bone 
standing  behind  the  acetabulum  so  that  the  pelvis  inclines  forward, 
and  also  because  in  walking  the  head  of  the  thigh  moves  up  and  down ; 
there  is  never  any  pain.  To  examine  the  child  more  accurately,  yc  u 
may  unclothe  it  entirely  and  watch  its  gait ;  then  lay  it  on  the  back 
and  compare  the  length  and  position  of  the  extremities.  If  the  luxa 
tion  be  one-sided,  the  luxated  limb  will  be  shorter  than  the  other,  and 
the  foot  turned  inward ;  if  you  fix  the  pelvis,  you  may  often  reduce 
the  dislocation  by  simple  traction  downward.  The  anatomical  exami- 
nation of  such  joints  has  led  to  the  following  results  :  not  only  is  the 
head  of  the  bone  out  of  the  socket,  but  the  socket  is  irregularly 
formed — too  shaEow ;  later  in  life,  in  adults,  it  is  greatly  compressed 


270  INJURIES  OF  THE  JOINTS. 

and  filled  witli  fat ;  when  the  ligamentum  teres  exists,  it  is  abnoi  mally 
long ;  the  head  of  the  bone  is  not  properly  developed ;  in  some  cases 
it  is  not  half  as  large  as  normal ;  the  articular  cartilage  is  usually 
completely  formed,  the  capsule  very  lar^e  and  relaxed. 

Under  such  circumstances,  you  may  understand  that  it  is  exceed- 
ingly difficult,  in  most  cases  impossible,  to  effect  a  cure.  If  the  head 
be  only  partially  developed,  the  upper  border  of  the  acetabulum  ab- 
sent, and  the  capsule  enormously  distended,  how  shall  w^e  restore  the 
normal  conditions  ?  As  to  the  causes  of  this  malformation,  the  most 
varied  hypotheses  have  been  advanced ;  the  opportunity  has  never 
occurred  of  studying  it  in  the  embryo.  There  is  an  arrest  of  develop- 
ment from  some  cause.  It  is  assumed  that  these  disturbances  followed 
previous  pathological  processes  in  the  foetus,  and  the  most  probable 
hypothesis  is  that,  in  very  early  embryonal  life,  the  joint  was  fiiUed 
with  an  abnormal  quantity  of  fluid,  and  so  distended  as  to  induce  rup- 
ture or  at  least  great  dilatation  of  the  capsule.  Jloser  thinks  that 
abnormal  intra-uterine  positions  may  give  rise  to  these  luxations. 

Cure  of  this  state  has  been  attempted  in  those  cases  where  direct 
examination  has  shown  the  existence  of  a  tolerably-developed  head. 
In  such  cases  the  luxation  has  been  reduced,  and  attempts  made  to 
preserve  the  normal  position  of  the  thigh  by  aid  of  dressings  or  band- 
ages— the  child  being  kept  quiet  for  a  year  or  more.  The  result  of 
this  treatment,  which  requires  great  patience  on  the  j^art  of  the  sur- 
geon and  parents  of  the  child,  is  shown  by  experience  to  be  only 
partially  satisfactory,  as  after  this  treatment  there  has  only  been  an 
improvement  of  the  gait,  but  rarely  a  perfect  cure ;  and,  when  you  read 
in  orthopedic  pamphlets  of  the  frequent  cure  of  congenital  luxations, 
you  may  be  sure  that  in  most  cases  there  have  been  errors  of  diag- 
nosis, or  there  is  intentional  deception. 

Congenital  luxations  of  the  thigh  are  never  dangerous  to  life,  but, 
since  they  are  accompanied  by  a  change  in  the  centre  of  gravity  of 
the  body,  in  the  course  of  time  they  have  an  effect  on  the  position 
and  curvature  of  the  vertebral  column ;  this,  and  a  limping,  wabbling 
gait,  are  the  only  inconveniences  they  cause.  There  can  only  be  a 
hope  of  successful  treatment  in  very  early  youth  ;  but,  as  the  'surgeon 
cannot  promise  a  successful  result  in  less  than  one  to  three  years,  few 
patients  are  put  under  treatment. 

I  will  here  mention  a  very  rare  occurrence,  which  I  have  only 
met  with  once.  In  certain  movements  the  tendon  of  the  long  head 
cf  the  biceps  brachii  may  slip  out  of  its  groove  and  hang  on  the  bor- 
der of  the  greater  or  lesser  tubercle  ;  then  the  arm  stands  fixed  in  a 
slightly  abducted  position.  If  we  hold  the  shoulder-blade  steady 
and  relax  the  tendon  by  slowly  raising  the  arm,  then  by  slightly 


CONGENITAL  LUXATIONS.  271 

rotating  the  arm  we  can  easily  slip  the  tendon  into  place  ;  the  pain 
ceases  at  once,  and  all  motions  are  free.  For  this  luxation  to  occur, 
the  fascia-like  membrane  which  covers  the  sulcus  must  tear  or  be 
much  relaxed.  The  former  is  improbable  ;  where  the  latter  is  the 
case,  the  accident  readily  recurs.  Some  persons  have  the  covering 
of  the  sulcus,  in  which  the  tibialis  posticus  muscle  lies,  so  relaxed 
that  they  can  voluntarily  luxate  this  tendon  and  let  it  snap  into 
place  with  an  audible  sound. 

[Cases  where  the  tendon  of  the  quadriceps  femoris  and  patella 
may  be  voluntarily  luxated  and  snapped  back  into  place  are  prob- 
ably less  rare.  The  translator,  among  other  cases,  has  had  one  pa- 
tient 18  months  old  who  could  do  this  at  pleasure,  and  when  irritated 
about  any  thing  would  snap  his  jDatella  even  if  his  leg  were  firmly 
held.  This  leg  having  been  placed  in  a  plaster  dressing,  he  began 
the  same  performance  with  the  other  leg.  Then  both  legs  were  left 
free,  and  after  some  weeks,  when  his  general  health  and  temper  im- 
proved, the  phenomenon  ceased.] 

[In  diagnosis  you  may  exclude  luxation  when  the  region  of  the 
joint  is  filled  and  there  is  no  pathognomonic  depression  where  it 
should  occur  ;  for  instance,  in  fracture  of  the  humerus  without 
luxation  the  normal  rounding  of  the  shoulder  will  be  present,  and 
on  palpation  you  can  discover  the  head  of  the  humerus  in  the  gle- 
noid fossa. 

When  luxations  have  existed  a  long  time,  the  articular  cavity 
becomes  filled  with  neoplastic  cicatricial  tissue  ;  this,  with  the  fixa- 
tion of  the  dislocated  head  of  the  bone,  binders  reduction. 

In  attempting  reductions  of  old  dislocations  we  must  bear  in 
mind  the  liability  to  rupture  of  atheromatous  arteries,  or  of  those 
that  have  become  adherent  to  cicatrices  ;  the  latter  complication  is 
especially  dangerous  with  large  venous  or  nerve  trunks. 

Abnormal  mobility  of  a  joint  after  luxation  is  not  solely  due  to 
continuance  of  the  rujjture  of  the  capsule  or  stretching  of  the  cica- 
trix in  it,  for  it  does  not  enclose  the  ends  of  the  bone  so  closely 
that  it  would  prevent  luxation  ;  this  is  done  by  atmospheric  press- 
ure, and  also  by  the  articular  ligaments  and  tendinous  aponeuroses 
woven  into  the  capsule.  In  every  complete  dislocation  these  are 
torn  ;  like  all  fibrous  tissues  they  heal  with  difficulty,  and  if  move- 
ments are  begun  before  consolidation  is  complete  the  parts  separate 
and  the  joint  remains  abnormally  movable. 

When  a  dislocation  has  existed  a  long  time,  and  the  cavity  has 
not  been  filled  up,  it  becomes  too  small  for  the  head  of  the  bone, 
just  as  the  orbit  decreases  in  size  after  removal  of  an  eye,  on  ac- 
count of  reduced  pressure  on  one  side. 


272  INJURIES  OF  THE  JOINTS. 

When  diminished  motion  is  due  to  adhesions  about  the  joint, 
these  may  be  broken  u])  during  anaesthesia  by  forced  rotation  of 
the  head  of  the  bone. 

In  irreducible  hixations  the  question  may  arise  as  to  opening 
the  joint ;  under  our  present  antiseptic  methods  this  operation 
would  not  be  dangerous,  but  it  is  rarelj^  indicated,  for  recent  dislo- 
cations can  almost  always  be  reduced,  and,  when  they  cannot,  even 
opening  the  joint  does  not  aid  a  great  deal. 

When  fracture  occurs  with  luxation  we  ordinarily  delay  trying 
to  reduce  the  latter  till  the  former  has  united  ;  of  course,  if  the 
reduction  can  be  readily  done  it  should  be  first  attended  to. 

Among  the  dislocations  should  be  classed  a  peculiar  injury,  lux- 
ation of  the  semilunar  cartilages  of  the  knee  ;  this  is  very  rare  un- 
less there  are  other  changes  in  the  joint,  so  that  its  occurrence  is 
actually  doubted  ;  but  it  does  occur,  and  comes  as  an  habitual  luxa- 
tion. Usually  it  is  the  inner  cartilage  Avhich  shoves  forward,  so 
that  the  inner  condyle  of  the  femur,  instead  of  sliding  on  the  carti- 
lage, slips  behind  it.  The  displacement  usually  occurs  on  forced 
flexion  of  the  joint,  the  toes  at  the  same  time  turning  outward. 
The  symptoms  are,  fixation  of  the  knee  in  imperfect  extension  with 
slight  external  rotation  of  the  foot ;  if  we  try  to  rotate  the  knee, 
there  are  resistance  and  pain,  the  knee  may  be  flexed  to  a  right  an- 
gle, the  cartilage  may  be  felt  at  the  anterior  border  of  the  joint.] 


CHAPTER  Ylil. 
G  UNSH  0  T-WO  UKD  .8 


LECTURE  XIX. 

Dietorical  lieinarks. — Injuries  from  Large  Missiles. — Various  Forms  of  Bullet- Wounds. 
— Transportation  and  Care  of  the  Wounded  in  the  Field. — Treatment. — Complica- 
ted Gunshot-Fractures. 

In  war  many  injuries  occur  that  are  to  be  classed  among  simple 
incised,  cut,  punctured,  and  contused  wounds  ;  gunshot-wounds  them- 
selv^es  must  be  classed  with  contused  wounds ;  but  they  have  some 
peculiarities  that  entitle  them  to  separate  consideration,  in  doing 
which  we  must  briefly  come  in  contact  with  the  domain  of  military 
surgery.  Since  fire-arms  were  first  used  in  warfare  (1338),  gunshot- 
wounds  have  received  special  attention  from  surgical  writers,  so  that 
the  literature  on  this  subject  has  become  very  extensive  ;  of  late,  in- 
deed, military  surgery  has  been  made  almost  a  separate  branch,  which 
includes  the  care  of  soldiers  in  peace  and  war,  and  the  special  hygienic 
and  dietetic  rules  which  are  so  important  in  barracks,  in  stationary 
and  field  hospitals,  also  the  clothing  and  food.  Although  the  Romans, 
as  was  mentioned  in  the  introduction,  had  surgeons  appointed  by  the 
state  with  the  army,  in  the  middle  ages  it  was  more  common  for  every 
leader  of  a  troop  to  have  a  private  doctor,  who,  with  one  or  more 
assistants,  very  imperfectly  took  care  of  the  soldiers  after  a  battle, 
and  then  usually  went  on  with  the  army,  leaving  the  wounded  to  the 
care  of  compassionate  people,  without  the  commander  or  the  army 
taking  the  responsibility. 

It  was  not  till  standing  armies  were  formed  that  surgeons  were 
detailed  to  certain  battalions  and  companies,  and  certain  (still  very 
imperfect)  rules  and  regulations  were  made  for  the  care  of  the 
wounded.  The  position  of  military  surgeon  was,  in  those  days,  very 
gnoble,  and  such  as  we  do  not  hear  of  now  ;  for,  even  in  the  time  of  the 
father  of  Frederick  the  Great,  the  army  surgeon  Avas  publicly  flogged 
if  he  permitted  one  of  the  long  grenadiers  to  die.  At  that  time,  wheo 
19 


274  VARIOUS  FORMS   OF  BULLET-WOUNDS. 

the  troops  marcbed  to  meet  the  enemy  at  a  parade-step,  the  move- 
ments of  the  army  were  very  tedious  and  slow ;  the  large  armies  had 
immense  trains ;  for  instance,  in  the  Thirty  Years'  War,  the  lancers  car- 
ried along  their  wives  and  children  in  innumerable  wagons  ;  hence,  in 
the  medical  arrangements  pertaining  to  the  train,  there  was  no  ne- 
cessity for  greater  facilities  of  motion.  The  tactics  started  by  Fred- 
erick the  Great  required  greater  mobility  of  the  heavy  trains,  which, 
however,  was  only  practically  carried  out  in  the  French  army  under 
Naj)oleon.  As  long  as  a  small  province  remained  the  seat  of  war 
during  a  whole  cami:)aign,  a  few  large  hospitals  in  neighboring  cities 
might  suffice  ;  but,  when  armies  moved  about  rapidly  and  had  a  fight 
now  here  now  there,  it  became  necessary  to  furnish  more  movable, 
so-called  field  hospitals,  not  far  from  the  field  of  battle,  and  which 
could  be  readily  moved  from  place  to  place.  These  ambulances,  or 
flying  hospitals,  are  the  idea  of  one  of  the  greatest  of  surgeons,  Lar- 
rey,  of  whom  we  have  already  spoken.  As  I  shall  shortly  tell  j'^ou 
what  is  done  with  the  wounded  from  the  time  the}'  are  injured  till 
they  enter  the  general  hospital,  I  will  here  dismiss  this  subject,  and 
only  mention  some  of  the  many  excellent  works  on  military  surgery. 
Especiallj'  interesting,  not  only  medically  but  historically,  are  the 
somewhat  lengthy  "  Memoirs  of  Larrey,"  in  which  I  especially  recom- 
mend to  you  the  Egyptian  and  Russian  campaigns.  These  memoirs 
contain  all  Napoleon's  campaigns.  Another  excellent  work  we  have 
in  Enghsh  literature,  JTohn  Sennen^s  "Principles  of  Military  Sur- 
gery ; "  and  in  German,  besides  many  other  excellent  works,  we  have 
''  The  Maxims  of  Military  Surgery,"  by  Stromeyer,  which  is  composed 
chiefly  of  experiences  in  the  Schleswig-Holstein  War ;  and,  lastly, 
■'  Principles  of  General  ISIilitary  Surgery,  from  Reminiscences  in  the 
Crimea  and  Caucasus,  and  in  the  Hospital,"  by  Dr.  Pirogoff. 

Wounds  caused  by  large  missiles,  such  as  cannon-balls,  grenades, 
bombs,  shrapnel,  etc.,  are  partly  of  such  a  nature  that  they  kill  at  once, 
in  other  cases  tear  off  whole  extremities,  or  so  shatter  them  that  am- 
putation is  the  only  remedy.  The  extensive  tearing  and  crushing 
caused  by  these  shot  do  not  differ  from  other  large  crushed  wounds 
caused  by  machinery,  Avhich  unfortunately  now  so  often  occur  in 
civil  practice. 

Musket-balls  used  in  modern  warfare  differ  in  some  respects : 
while  the  small  copper  bullets  with  which  the  Circassians  shoot  are 
scarcely  larger  than  our  so-called  buckshot,  large,  hollow,  leaden  bul- 
lets were  used  in  the  late  Italian  War ;  these  were  much  larger  than 
the  old-fashioned  ones,  and  were  particularly  dangerous,  because  they 
readily  broke  upon  striking  a  bone  or  tense  tendon.  Besides  these, 
the  solid  round  and  conical  bullet  are  used,  but  their  effects  do  not 


GUNSHOT-WOUNDS. 


275 


Fig.  58. 


a,  Chassepot ;  h,  needle-gun ;  c,  mitrailleuse-projectiles.    Natural  size. 


differ  much.  The  Prussian  long  bullet,  which  is  held  in  the  cartridge 
of  the  needle-gun,  is  a  solid  bullet  of  the  form  and  size  of  an  acorn. 
You  must  not  think  that  the  projectile,  as  found  in  the  wound,  has  the 
same  shape  as  when  put  in  the  gun  ;  but  it  is  changed  in  form  as  it 
comes  out  of  the  rifles  of  the  gun,  and  is  also  flattened  in  the  wound, 
so  that  we  often  find  it  a  shapeless  mass  of  lead,  which  scarcely  shows 
the  form  of  the  projectile.  We  shall  now  briefly  consider  the  various 
injuries  that  may  be  caused  by  a  bullet ;  in  doing  which,  we  shall 
naturallj^  confine  ourselves  to  the  chief  forms. 

In  one  set  of  cases  the  bullet  makes  no  wound,  but  simply  a  con- 
tusion of  the  soft  parts,  accompanied  by  great  suggillation  and  occa- 
sionally by  subcutaneous  fracture.  According  to  recent  authorities, 
simple  subcutaneous  fi^actures  are  not  very  uncommon  in  war.  These 
injm'ies  are  caused  by  spent  bullets,  i.  e.,  such  as  come  from  a  long  dis- 
tance and  have  not  force  enough  to  penetrate  the  skin ;  such  a  bullet, 
striking  over  the  liver,  may  push  the  skin  before  it  and  make  a  depres- 
sion in  or  a  rupture  of  the  liver,  and  then  fall  back  without  producing  an 
external  wound.  Like  injuries  are  caused  by  bullets  striking  the  skin 
at  a  very  oblique  angle.  Firm  bodies,  such  as  watches,  pocket-books, 
coins,  leather  straps  on  the  uniform,  etc.,  may  also  arrest  the  bullet. 
These  contused  Avounds,  which,  especially  when  aff"ecting  the  abdomen 
or  thorax,  may  prove  very  dangerous,  have  always  excited  the  atten- 
tion of  surgeons  and  soldiers ;  formerly  they  were  always  referred  to 
the  so-called  "  wind  of  the  ball,"  and  it  was  thought  that  they  were 
caused  by  the  bullet  passing  very  close  to  the  body.  The  idea  thai 
injuries  could  be  caused  in  this  way  was  so  firmly  established,  that 
even  very  well-informed  persons  worried  themselves  in  trying  to  ex- 
plain theoretically  how  the)'"  resulted  from  the  wind  of  the  ball.  One 
said  that  the  air  in  front  of  and  near  the  bullet  was  so  compressed 


276  VARIOUS  FORMS  OF  BULLET-WOUNDS. 

tliat  the  injury  was  due  to  this  pressure ;  another  thought  that,  from 
the  friction  in  the  barrel  of  the  gun,  the  bullet  was  charged  with 
electricity,  and  could  in  some  unknown  manner  cause  contusion  and 
burnino-  at  a  certain  distance.  If  the  conclusion  that  the  whole  idea 
of  the  wind  of  balls  was  a  fable  had  been  arrived  at  sooner,  these 
fantastic  theories  would  not  have  arisen.  Contusions  from  spent  and 
oblique  bullets  are  to  be  treated  like  other  contusions. 

In  the  second  case,  the  bullet  does  not  enter  the  soft  parts  deeply, 
but  carries  away  part  of  the  skin  from  the  surface  of  the  body,  leaving 
a  gutter  or  furrow.  This  variety  of  gunshot-wound  is  one  of  the 
slightest,  unless,  as  may  happen  in  the  head,  the  bone  is  grazed  by 
the  bullet,  and  portions  of  lead  remain  in  the  skull. 

The  third  case  is  where  the  bullet  enters  the  skin  without  escap- 
ing again ;  the  bullet  enters  and  generally  remains  in  the  soft  parts ; 
it  makes  a  tubular  wound.  Various  other  foreign  bodies  may  be  car- 
ried into  these  wounds,  such  as  portions  of  uniform,  cloth,  leather, 
buttons,  etc. ;  a  bone  may  also  be  spUntered,  and  the  splinters  driven 
into  the  wound  and  tear  it.  After  perforating  tlie  skin  and  soft 
parts,  the  bullet  might  rebound  from  a  bone  and  fall  out  of  the  same 
opening,  so  that  you  would  not  find  it  in  the  wound,  in  spite  of  there 
being  only  one  opening.  The  wound  that  the  bullet  makes  on  entering 
the  body  is  usually  round,  corresponding  to  the  shape  of  the  ball ;  its 
edges  are  contused,  occasionally  bluish-black,  and  somewhat  inverted. 
These  characteristics  liold  in  the  majority  of  cases,  but  are  not  ab- 
solute. 

The  fourth  and  last  case  is  where  the  bullet  enters  at  one  point  and 
escapes  at  another.  If  the  course  of  the  wound  is  entirely  through 
the  soft  parts,  and  the  bullet  has  carried  in  no  foreign  body,  the  point 
of  exit  is  usually  smaller  than  the  entrance,  and  is  more  like  a  tear. 
If  the  bullet  has  struck  a  bone  and  driven  bone-splinters  or  other  for- 
eign body  before  it,  the  point  of  exit  is  occasionally  much  larger  than 
the  entrance ;  there  may  also  be  two  or  more  points  of  exit  from 
bursting  of  the  bullet  into  several  pieces  or  from  several  splinters  of 
bone.  Lastly,  splinters  of  bone  may  make  openings  of  exit  like  those 
from  a  bullet,  while  the  latter,  or  part  of  it,  remains  in  the  wound. 
Too  much  value  has  been  attached  to  the  distinction  of  the  openings 
of  entrance  and  exit ;  this  is  only  important  in  forensic  cases,  where 
it  may  be  desirable  to  know  from  which  side  the  bullet  came,  as  this 
may  give  a  clew  to  the  author  of  the  injury.  The  courseof  the  bullet 
through  the  deep  parts  is  occasionally  very  peculiar ;  its  course  is  some- 
times deviated  by  bones  or  tense  tendons  and  fasciae,  so  that  we 
should  be  greatly  mistaken  in  supposing  that  the  union  of  the  points 
of  entrance  and  exit  by  a  straight  line  always  represented  the  course 


GUNSHOT-WOUNDS.  277 

of  tlie  bullet.  In  this  respect,  the  encircling  of  the  skull  and  thorax 
is  most  peculiar  :  for  instance,  a  bullet  strikes  the  sternum  obliquely, 
but  without  sufficient  force  to  perforate  this  bone ;  the  bullet  may 
run  along  a  rib  under  the  skin  to  the  side  of  the  thorax,  or  even  to 
the  spinal  column,  before  escaping  again  ;  from  the  position  of  the 
points  of  entry  and  exit,  we  might  suppose  the  bullet  had  passed 
directly  through  the  chest,  and  be  greatly  astonished  when  such 
patients  come,  without  any  difficulty  of  breathing,  to  have  their  wound 
dressed. 

The  complication  of  gunshot-wounds  with  burns  by  powder,  such 
as  results  from  shooting  at  close  quarters,  rarely  occurs  in  war.  It  is 
not  rare  in  cases  of  accidents  from  careless  handling  or  bursting  of 
fire-arms,  or  from  blasting,  and  may  cause  the  greatest  variety  of 
burn.  The  burnt  particles  of  powder  often  enter  the  skin  and  heal 
there,  giving  it  a  bluish-black  appearance  for  the  rest  of  life.  More 
of  this  in  the  chapter  on  burns. 

In  gunshot  injuries,  there  is  said  to  be  scarcely  any  pain ;  the  rapidity 
of  the  injury  is  such  that  the  patient  only  feels  a  blow  on  the  side 
from  which  the  bullet  comes,  and  does  not  for  some  time  perceive  the 
bleeding  wound  and  actual  pain.  There  are  numerous  examples 
where  combatants  have  received  a  shot,  especially  in  the  upper  ex- 
tremity, without  knowing  it  till  told  by  some  one,  or  having  their 
attention  attracted  by  the  flow  of  blood. 

In  gunshot,  as  in  contused  wounds,  the  bleeding  is  usually  less 
^han  in  incised  and  punctured  wounds ;  but  it  would  be  a  great  mis- 
take to  suppose  that  arteries  which  have  been  shot  through  do  not 
bleed.  On  the  contrary,  many  soldiers  never  leave  the  battle-field, 
having  died  from  rapid  hemorrhage  from  large  arteries.  When  one 
has  seen  a  fully-divided  carotid,  subclavian,  or  femoral  artery  bleed, 
he  will  know  that  in  a  very  short  time  the  loss  of  blood  will  be  so 
great  that  the  only  hope  of  safety  lies  in  immediate  aid ;  so  that  a 
haemorrhage  of  two  minutes'  duration  from  one  of  these  arteries  is 
certainly  fatal.  But  arteries,  even  as  large  as  the  radial,  often  bleed 
but  little.  The  first  surgeons  who  gave  us  descriptions  of  gunshot- 
wounds  called  attention  to  this  point. 

Before  passing  to  the  treatment  of  gunshot-wounds,  I  would 
briefly  picture  to  you  the  transportation  of  and  first  aid  ofl'ered  to  the 
wounded  in  battle.  For  the  first  aid  there  are  usually  established 
certain  temporary  places  for  dressing  the  wounded,  in  some  sheltered 
place  close  behind  the  line  of  battle,  usually  in  rear  of  the  batteries ; 
these  are  designated  by  white  flags.  The  wounded  are  first  brought 
to  this  spot,  either  by  soldiers  or  by  a  trained  ambulance  corjDS.  Of 
course,  those  wounded  slightly  or  in  the  upper  extremities  walk  to  the 


278  CARE   OF   THE   WOUNDED. 

spot.  The  ambulance  corps  has  proved  so  efficient  in  late  wars  that 
it  will  certainly  be  more  trusted  to  in  future.  It  is  composed  of 
nurses  trained  to  bring  the  wounded  from  the  field,  and,  when  neces- 
sary, to  give  them  temporary  aid,  as  in  arresting  bleeding  from  arte- 
ries and  wounds,  etc.  They  have  been  trained  to  carry  a  patient 
between  tAvo  of  them,  either  without  other  support,  or  on  an  impro- 
vised litter.  For  this  latter  purpose  they  usually  carry  a  lance  and  a 
piece  of  cloth  longer  and  broader  than  the  body.  The  lances  are 
passed  through  hems  along  the  sides  of  the  cloth,  and  a  barrow  is 
thus  made  ;  bayonets  or  SAVords  may  be  used  as  provisional  splints  for 
supporting  a  limb  that  has  been  badly  shot.  The  wounded  are  thus 
brought  to  the  dressing-place,  and  the  first  dressings  are  applied ; 
these  remain  on  till  the  patient  reaches  the  nearest  field-hospital.  At 
the  same  time  hemorrhage  must  be  securely  arrested,  and  injured 
limbs  so  arranged  that  transportation  may  do  no  harm ;  bullets,  for- 
eign bodies,  and  loose  splinters  of  bone  near  the  surface,  should  be 
removed,  if  it  can  be  done  quickly  and  readily.  Limbs  that  have 
been  entirely  crushed  by  large  shot  should  be  at  once  amputated,  if  a 
dressing  cannot  be  so  applied  as  to  render  transportation  possible. 
The  chief  object  of  this  dressing-place  is  to  render  the  wounded 
transportable ;  hence  it  is  not  proper  to  do  many  or  tedious  operations 
there.  From  the  great  pressure  of  the  constantly-increasing  throng 
from  the  front,  only  the  most  important  cases  can  be  attended  to  here, 
and  Pirogoff  is  right,  though  it  seems  cruel,  Avhen  he  says  the  sur- 
geons should  not  exhaust  their  strength  on  the  mortally  wounded  and 
the  dying.  But,  if  possible,  every  patient,  when  cari-ied  to  the 
field-hospital,  should  receive  a  short  written  account  of  what  was 
found  at  the  first  examination  ;  a  card,  containing  a  few:  words,  thrust 
into  one  of  his  pockets  is  enough.  The  chief  point  is  to  tell  whethei 
the  ball  has  been  extracted,  whether  a  wound  of  the  breast  or  abdo- 
men is  perforating,  etc.,  which  will  save  time  to  the  surgeon  at  the 
hospital  and  pain  to  the  patient.  Part  of  the  ambulance  corps  has 
the  further  duty  of  placing  the  wounded  properly  in  wagons  for  fur- 
ther transportation,  under  direction  of  the  surgeon.  For  this  purpose 
there  are  special  ambulances,  constructed  most  variously,  which  take 
some  patients  lying  down,  others  sitting  up.  There  are  rarely  enough 
of  these,  and  it  is  often  necessary  to  use  common  wagons,  covered 
with  hay,  straw,  etc.  These  wagons  convey  the  wounded  to  the  next 
field-hospital,  which  is  established  in  a  neighboring  city  or  town ; 
for  it  the  largest  attainable  rooms  should  be  taken.  School-houses, 
churches,  or  barns,  may  be  seized,  although  the  latter  are  the  best. 
In  these  places  beds  are  prepared  with  straw,  a  few  mattresses,  and 
bedclothes.     Surgeons  and  nurses  await  anxiously  the  arrival  of  the 


GUNSHOT-WOUNDS.  279 

iivit  load  of  patients,  having  been  already  notified  of  the  commence- 
ment of  the  battle  by  the  thunder  of  the  artillery.  Here  begins  the 
accurate  examination  of  patients,  who  were  only  temporarily  dressed 
on  the  field,  and  here  operating  goes  on  most  actively.  Amputations, 
resections,  extractions  of  bullets,  etc.,  are  done  by  wholesale,  and  the 
suro-eon  who  has  been  anxious  for  his  first  operation  on  a  living 
patient  may  operate  till  he  stops  from  exhaustion.  This  continues 
till  far  into  the  night ;  the  fight  lasts  till  late  in  the  evening,  and  it  is 
near  morning  before  the  last  loads  of  Avounded  come  in.  With  bad 
lio-hts,  on  a  tempoi'ary  operating-table,  and  often  with  unskilful  nurses 
for  assistants,  the  surgeon  must  at  once  examine  every  patient,  down 
to  the  last,  and  then  operate  and  dress  his  wounds.  In  the  field-hos- 
pitals the  wounded  have  a  period  of  rest,  and,  if  possible,  those  who 
have  been  operated  on  or  are  seriously  hurt  should  not  be  moved  to 
another  hospital  till  healthy  suppuration  begins  and  healing  has  at 
least  commenced.  This  cannot  always  be  done.  Occasionally  the 
place  where  the  field-hospital  has  been  established  must  be  vacated. 
If  one  belongs  to  the  vanquished  part}^,  and  the  enemy  takes  the  place 
where  the  field-hospital  was  established,  the  surgeons  are  usually  taken 
prisoners  with  their  wounded;  for,  even  when  the  enemy  is  most 
humane,  after  a  great  battle  there  is  often  such  a  demand  for  surgeons 
that  those  of  the  enemy  cannot  take  the  projDer  care  of  wounded 
prisoners.  A  few  years  since,  in  Geneva,  a  convention  of  European 
powers  determined  that  surgeons  and  sanitary  supplies  should  be  con 
sidered  neutral.  Although  there  are  some  practical  difficulties  in 
carrying  out  this  principle,  it  has  done  great  good  in  the  wars  of  late 
years,  and  is  capable  of  still  further  development.  At  all  events,  the 
idea  of  considering  a  wounded  enemy  as  an  enemy  no  longer,  but  as 
a  patient,  is  to  be  prized  as  a  beautiful  evidence  of  advancing  hu- 
manity. 

When  the  wounded  have  all  been  brought  under  cover,  bedded, 
and  the  necessary  operations  done,  and  the  diet,  etc.,  has  been  at- 
tended to,  arrangements  should  be  made  for  their  proper  disposition. 
Permanent  collection  of  many  wounded  men  in  one  place  is  injurious, 
and,  when  the  seat  of  war  is  a  poor  country,  Avith  few  railroad  con- 
nections, the  care  of  the  wounded  is  particularly  difficult.  Hence, 
they  should  be  sent  off  as  soon  as  possible.  This  may  be  done,  even 
with  the  severely  wounded,  when  there  is  a  railroad  handy ;  when  the 
transportation  is  less  convenient,  the  more  slightly  wounded  at  least 
can  be  removed.  This  system  of  scattering,  which  of  late  has  been 
conducted  with  excellent  results,  requires  great  circumspection  and 
trouble  from  the  superior  medical  and  military  authorities,  but  it  haa 
proved  advantageous.     If  houses  (baiTacks),  or,  in  summer,  tents,  can 


280  TREATMENT  OF  GUNSHOT-WOUNDS. 

be  erected  for  those  remaining — the  severely  wounded — that  will  be 
best.  If  this  be  not  practicable,  they  may  be  distributed  in  private 
houses ;  it  has  proved  unadvisable  to  leave  the  wounded  in  school- 
houses  and  churches. 

The  war  in  North  America,  as  well  as  that  between  Austria  and 
Prussia  in  1866,  showed  that  there  were  still  improvements  to  be 
made  in  military  sanitary  arrangements.  A  factor  has  been  added 
that  never  before  came  as  an  aid,  namely,  extensive  assistance  from 
societies,  Sisters  of  Charity,  civil  surgeons,  and  many  other  persons 
who,  either  personally  or  by  money  and  stores,  aided  in  the  care  of 
the  wounded.  "Wlien  this  private  aid  is  properly  organized,  under 
proper  management  of  the  military  officers,  it  may  be  very  useful. 

Concerning  the  treatment  of  gunshot-wounds,  views  have  greatly 
changed  from  time  to  time,  according  to  the  point  of  view  from  which 
they  were  regarded.  The  oldest  surgeons  whose  opinions  Ave  have, 
considered  them  as  poisoned,  and  thought,  consequently,  that  they 
should  be  treated  with  the  hot  iron  or  boiling  oil.  The  first  to  op- 
pose this  vaew  successfully  was  Ambrose  Fare,  whom  you  already 
know  to  have  introduced  the  ligature  for  arteries.  He  relates  that  in 
the  campaign  in  Piedmont  (1536)  he  ran  short  of  oil  for  burning  the 
wounds,  and  he  expected  the  death  of  all  the  patients  who  could  not 
be  treated  according  to  the  rules  of  the  time.  But  this  did  not  haj> 
pen ;  on  the  contrar}^,  they  did  better  than  the  chosen  few  on  whom 
he  used  the  remains  of  his  oil.  Thus  a  lucky  accident  tolerably  soon 
freed  medicine  of  this  superstition.  Later  it  was  very  correctly  ob- 
served that  the  great  difficulty  in  healing  gunshot-wounds  was  due  to 
the  narrowness  of  the  canal,  and  attempts  were  made  to  obviate  this 
by  plugging  the  wound  with  charpie  or  gentian-root.  But  sensible 
surgeons  soon  saw  that  this  still  more  impeded  the  escape  of  pus 
from  the  deeper  parts,  and  the  correct  view  commenced  to  make 
some  headway,  that  a  gunshot-wound  was  a  tubvilar  contused  wound. 
They  sought  to  improve  this  in  a  peculiar  way,  by  laying  doAvn  the 
rule  that  every  superficial  gunshot-wound  should  be  laid  open,  the 
opening  of  a  canal  leading  into  the  deeper  parts  was  to  be  enlarged 
by  one  or  more  incisions ;  various  methods  were  proposed  for  chan- 
ging the  contvised  wound  into  a  simple  incised  wound  by  these  in- 
cisions, while,  in  fact,  the  only  thing  that  was  done  was  to  add  an 
incised  wound  to  the  gunshot-wound.  The  case  was  somewhat  dif- 
ferent when  the  rule  was  given  to  cut  out  the  whole  course  of  the 
canal,  and  close  the  resulting  canal  by  sutures  and  compresses,  so  as 
to  obtain  healing  by  first  intention  ;  this  proceeding  cannot  often  be 
applied,  and  obtained  little  reputation.  Of  late,  since  the  treatment 
of  all  wounds  is  so  much  simplified,  the  same  thing  has  happened  to 


GUNSHOT-WOUNDS. 


281 


gtmsliot-wounds  which  are  treated  on  the  same  general  prmciples  as 
contused  wounds.  In  these,  as  in  other  wounds,  the  first  thing  is  to 
arrest  any  arterial  haemorrhage.  This  is  to  be  done  according  to  the 
rules  already  given,  the  bleeding  artery 
being  tied  either  in  the  wound  itself,  or 
the  corresponding  arterial  trunk  being 
ligated  in  its  continuity  ;  to  accomplish 
the  former,  it  is  generally  necessary  to 
enlarge  the  opening  of  entrance  or  exit, 
otherwise  we  should  not  find  the  bleed- 
ing artery.  If  there  be  no  haemorrhage, 
we  should  examine  the  wound,  especially 
any  blind  canal,  for  foreign  bodies,  par- 
ticularly for  the  bullet.  This  may  be 
done  most  ceii-ainly  with  the  finger ; 
should  it  not  be  long  enough,  or  should 
the  canal  be  too  narrow,  we  may  best 
use  a  silver  female  catheter,  with  which 
we  may  feel  more  certainly  and  safely 
than  with  a  probe ;  if  we  feel  the  bullet, 
we  try  to  remove  it  the  shortest  way, 
that  is,  either  draw  it  out  at  the  point 
of  entrance,  or,  if  it  lies  in  a  blind  canal, 
close  under  the  skin,  we  make  an  inci- 
sion through  the  skin  and  extract  it 
throvTgh  this,  thereby  changing  the  blind 
canal  into  a  complete  one.  The  extrac- 
tion of  bullets  through  the  opening  of 
entrance  may  be  made  by  aid  of  spoon 
or  forceps-shaped  instruments.  Bullet- 
forceps  with  long,  thin  blades  are  often 
difficult  to  use,  because  they  cannot  be 
sufficiently  opened  in  the  narrow  canal 
to  seize  the  bullet,  hence  many  military 
surgeons  prefer  the  spoon-shaped  instru- 
ment. Such  a  bullet  scoop  has  lately 
been  suggested  by  H.  v.  Langenheck\ 
and  seems  very  practical  ;  in  it  the 
spoon  is  movable  so  as  to  pass  behind 
the  bullet,  and  push  it  forward.  Still  better,  it  seems  to  me,  is  a 
recently-invented  American  forceps,  whose  peculiarity  is  that  the}' 
can  be  opened  even  in  a  narrow  canal,  and  they  seize  very  securely. 
If  the  bullet  be  lodged  in  a  bone,  we  may  bore  a  long  gimlet  into  it, 


BuUet-foroeps,  made  by  Geo.  Tiemann 
&  Co.,  of  New  York,  with  sharp 
points  for  seizing  leaden  bullets. 


282  TREATMENT  OF  GUNSHOT-WOUNDS. 

and  try  to  extract  it  in  that  way.  If  we  do  not  succeed  in  removing 
the  bullet  or  other  foreign  body  by  the  opening  of  entrance,  we  proceed 
to  enlarge  it  to  gain  more  room  so  as  to  apply  the  instruments  better. 
The  experience  that  bullets  may  often  remain  in  the  body  without  in- 
jury should  warn  us  against  any  violent  operation  that  aims  only  at 
their  extraction.  Hence,  hsemorrhage  and  diificult  extraction  of  for- 
eign bodies  are  the  chief  indications  for  primary  dilatation  of  gunshot- 
wounds.  Later,  other  indications  may  arise  to  necessitate  it ;  but,  in 
the  gunshot-wound,  such  enlargement  is  not  necessary  for  a  cure.  This 
takes  place  by  the  throwing  off  of  a  small  ring-shaped  eschar,  and  the 
detachment  of  gangrenous  shreds  from  the  track  of  the  wound,  till 
healthy  granulation  and  suppuration  begin,  and  the  canal  gradually 
closes  from  within  outward.  In  most  cases  the  opening  of  exit 
cicatrizes  before  the  entrance.  Certain  obstacles  may  stand  in  the 
way  of  this  normal  course  ;  there  may  be  deep  progressive  inflamma- 
tions, rendering  necessary  new  incisions  and  the  employment  of  ice, 
as  in  other  deep  contused  wounds. 

The  first  dressing  of  a  gunshot-wound  in  the  field  is  usually  a 
moist  compress,  covered  with  a  bit  of  oiled  muslin  or  parchment- 
paper,  held  in  place  by  a  bandage  or  cloth.  Frequently  nothing 
further  is  required  than  simply  keeping  the  wound  moist  and  covered 
with  charpie,  lotions  of  lead-water,  chlorine-water,  etc.  As  yet  there 
are  no  full  oliservations  of  the  treatment  of  gunshot-wounds  without 
dressings.  They  occasionally,  though  rarely,  heal  by  first  intention ; 
as  a  rule,  they  suppurate  for  a  longer  or  shorter  period.  One  of  the 
chief  causes  of  deep  inflammation  is  the  presence  of  foreign  bodies, 
such  as  bits  of  clothing,  leather,  etc.  The  presence  of  the  bullet,  or 
a  portion  of  it,  is  far  less  dangerous,  for  the  cicatricial  tissue  may 
grow  around  and  entirely  encapsulate  the  lead,  while  the  wound 
closes  over  it;  the  patient  keeps  the  bullet  in  him.  But  these  bullets 
do  not  always  remain  in  the  same  spot ;  they  partly  sink,  from  their 
weight,  partly  are  displaced,  by  muscular  action,  so  that  after  years 
they  are  found  at  diff"erent  (generally  lower)  points :  for  instance,  a 
bullet  may  enter  the  thigh,  and  subsequently,  after  being  almost  for- 
gotten, may  be  felt  under  the  skin  of  the  calf  or  heel,  and  may  thence 
be  readily  extracted.  I  have  told  you  the  same  thing  about  needles. 
But  non-metallic  bodies  seem  never  able  to  remain  thus  without 
injury  in  the  human  bod}^,  and  hence  should  always  be  extracted 
when  discovered  in  a  wound. 

In  gunshot-wounds  the  fever  generally  depends  on  their  size  and 
extent,  as  well  as  on  the  accidental  suppuration.  In  the  excellently- 
directed  hospital  of  the  Bavarian  chief  staflF-surgeon  J^eck,  which  I 
visited  at  Tauberbischofsheim  (1866),  the  thermometer  was  used  for 


GUNSHOT-WOUNDS. 


283 


determiuing  the  amount  of  fever ;  the  results  as  to  fever  generally 
correspond  with  those  in  other  injviries. 

[^Demarquay  (quoted  in  the  Medical  Times  and  Gazette,  Septem- 
ber, 1871)  says  that  in  all  cases  observed,  where  the  temperature  fell 
below  95°  Fahr.,  the  patients  died.] 

The  special  rules  to  be  observed  in  perforating  wounds  of  the 
skull,  thorax,  and  abdomen,  are  given  in  special  surgery ;  let  us  here 
make  a  few  remarks  on  the  fractures  resulting  from  gunshot-wounds. 
We  have  already  stated  that  simple  subcutaneous  fractures  occur  from 
spent  or  obliquely-falling  bullets ;  but,  in  most  cases,  the  fractures  are 
accompanied  by  wounds  of  the  soft  parts.  The  soft,  spongy  bones 
and  the  epiphyses  may  be  simply  perforated  by  bullets  without  any 
splintering.  This  injury  is  comparatively  favorable ;  if  the  adjacent 
joint  be  not  opened,  the  bullet  may  remain  in  the  bone,  and,  if  it 
cannot  be  extracted,  may  heal  there  ;  the  track  of  the  wound  in  the 
bone  suppurates,  fills  with  granulations,  which  at  least  partly  ossify, 
so  that  the  firmness  of  the  bone  is  not  impaired.     If  the  bullet  strikes 


Fig.  CO. 


Femur  of  a  French  soldier,  broken 
by  a  needle-gup  bullet. 


Tibia  of  a  German  soldier  struck 
by  a  caassepot-projecUle. 


284  TREATMENT  OF  GUXSHOT-WOUXDS. 

the  diaphysis  of  a  long  boue,  it  generally  splinters  it,  and  does  so 
mucli  more  extensively  than  any  other  cause.  The  numbers  of  sharp 
splinters,  and  the  extent  of  the  spHntering  in  proportion  to  the  diame- 
ter of  the  projectile,  is  the  most  noticeable  feature  that  we  observe 
when  first  seeing  a  large  number  of  gunshot- wounds. 

I  think  it  is  necessary  and  very  important  to  examine  every  gun- 
shot-wound of  the  extremities  with  the  finger  quite  early,  and  to 
remove  fragments  that  are  loose  or  slightly  attached  to  the  soft  parts ; 
it  may  be  ad\'isable  now  and  then  to  cut  or  saw  off  pointed  frag- 
ments where  it  can  be  done  without  much  new  injury  or  extensive 
incisions  through  the  soft  parts.  But  I  would  not  recommend  these 
resections  hi  the  continuity  as  a  usual  or  necessary  operation,  for  ex- 
perience shows  that  many  such  cases  go  on  favorably  without  opera- 
tions. 

If  the  injury  has  caused  a  complicated  fracture  in  a  joint,  we  can- 
not hope  for  much  from  an  expectant  treatment,  according  to  present 
experience,  Avliich  is  based  on  statistics  ;  the  question  rather  seems  to 
be,  whether  primary  resection  or  amputation  is  preferable ;  this  can 
only  be  decided  by  the  peculiarities  of  each  case. 

Lastly,  we  must  mention  that  secondary  haemorrhages  are  par- 
ticularly frequent  in  gunshot  as  in  other  contused  wounds. 

I  consider  the  treatment  of  gunshot-fractures,  by  fenestrated  plas- 
ter-bandages, as  the  only  proper  method  (excepting  perhaps  those  in  the 
upper  part  of  the  arm  or  thigh)  ;  the  only  thing  against  it  is,  that 
surgeons  who  have  not  already  treated  open  fractures  with  plaster- 
dressings,  and  are  not  adepts  in  the  application,  should  not  make  their 
first  experiments  on  gunshot-fractures,  but  should  only  apply  dressings 
with  which  they  are  familiar. 

Secondary  suppurative  inflammations  occur  in  gunshot-wounds 
even  more  frequently  than  in  other  contused  wounds ;  the  same 
causes  that  we  have  already  learned  for  these  dangerous  accidents, 
unfortunately  often  act  in  gunshot-wounds  also. 

We  must  satisfy  ourselves  with  these  few  remarks  on  the  suljject 
of  gunshot-wounds,  glad  as  I  should  be  to  continue  the  subject.  Those 
who  feel  special  interest  in  the  subject,  I  refer  to  the  works  already 
mentioned,  and  to  a  little  book  of  ni}'-  OAvn,  "  Historical  Studies  on 
the  Consideration  and  Treatment  of  Gunshot- Wounds,"  in  which  you 
will  find  the  old  literature  brought  together. 

[In  the  recent  Turko-Russian  War  Lister's  treatment  was  tried  to 
some  extent  and  with  very  favorable  results,  as  shown  by  Reyher 
and  Beryniann  ;  in  the  next  war  between  civilized  nations  it  will 
doubtless  cause  decided  changes  in  field-practice.  Esmarch  has 
proposed  furnishing  to  every  soldier  going  into  battle  two  balls  of 


GUNSnOT-WOUNDS.  285 

salicylated  wadding  done  up  in  gutta-percha  cloth,  with  which  to 
cover  a  gunshot-wound  either  in  himself  or  a  comrade  ;  the  wad- 
ding unites  with  the  blood  to  form  a  provisional  antiseptic  dressing 
till  the  patient  comes  under  the  surgeon's  care.  EsmarcKs  experi- 
ence shows  that  this  dressing  may  stay  on  several  days,  and  that 
healing  under  it  may  occur  without  reaction  :  although  healing  by 
first  intention  has  been  observed,  it  is  very  rare  ;  gunshot-wounds 
usually  suppurate,  but  under  Lister's  dressing  small  wounds,  as 
those  made  by  pistol-balls,  not  unfrequently  heal  by  second  intention 
without  suppuration.  Klebs  made  some  very  accurate  pathologico- 
anatoraical  observations  on  gunshot- wounds  in  the  late  German- 
French  War ;  he  saw  perforating  wounds  of  chest  and  abdomen 
without  suppuration  or  inflammation  of  their  walls.  Klebs  supposed 
that  in  these  cases  valvular  closure  of  the  skin-wound  prevented  the 
entrance  of  air,  which  explained  the  absence  of  irritation  from  the 
injury  ;  such  results  are  rare,  and  are  not  to  be  expected. 

Antiseptic  treatment  of  gunshot  fractures  is  entirely  analogous 
to  that  of  other  compound  fractures.  Much  depends  on  the  injury 
to  the  soft  parts  ;  if  they  are  much  crushed,  permanent  irrigation 
may  be  indicated;  otherwise  the  seat  of  fracture  may  be  left  ex- 
posed, disinfected,  washed  with  concentrated  solution  of  chloride 
of  zinc,  and  placed  in  a  Listens  dressing  and  in  splints,  or  a  fixed 
dressing.  If  the  wound  be  not  too  long  or  deep,  it  will  be  best  to 
lay  it  open,  remove  the  crushed  tissue,  disinfect,  drain,  and  then 
unite  by  deep  and  superficial  sutures  ;  this  gives  better  chance  of 
healing  without  reaction  than  when  we  have  to  disinfect  by  injec- 
tions, etc. 

At  present  with  Lister's  dressing  we  apply  wooden  or  gutta- 
percha splints,  or  else  permanent  extension  instead  of  fenestrated 
plaster  splints,  as  formerly.] 


CHAPTER  IX. 
buhj^s  and  fbost-bites. 


LECTURE    XX. 

\    Sums:    Grade,  Extent,    Treatment. — Sunstroke. — Stroke  of  Liglitnmg.— 2.  Frost" 
bites :  Grade, — General  Freezing,  Treatment. — Chilblains. 

The  symptoms  due  to  burns  and  frost-bites  are  quite  similar,  but 
are  sufficiently  distinct  to  be  regarded  separately ;  we  shall  first  treat  of 

BUENS. 

ITiese  are  caused  by  the  flames,  when,  for  instance,  the  clothes  burn, 
but  more  frequently  by  hot  fluids,  as  when  children  jjull  vessels  of  hot 
water,  coffee,  soup,  etc.,  ^ff  a  table  on  to  themselves.  And,  unfor- 
tunately, in  factories,  burns  from  hot  metals,  such  as  molten  lead,  iron, 
etc.,  are  not  rare,  and  in  every-day  life  slighter  burns  from  matches, 
sealing-wax,  etc.,  often  occur,  as  you  have  all  doubtless  seen.  Besides 
the  above,  concentrated  acids  and  caustic  alkalies  not  unfrequently 
cause  burns  of  various  degrees,  analogous  to  those  from  hot  bodies. 

In  burns  the  intensity  and  extent  of  the  injury  are  to  be  regarded; 
we  shall  hereafter  study  the  latter.  The  intensity  of  the  burn  de- 
pends essentially  on  the  grade  of  the  heat  and  the  duration  of  its 
action  ;  according  to  the  result  of  this  action,  burns  have  been  divided 
into  three  grades.  These  pass  into  one  another,  but  from  the  acccom- 
panying  sj^mptoms  may  be  distinguished  without  difficulty ;  the  only  ob- 
ject of  this  is  to  render  explanation  easier.      We  assume  three  grades. 

First  degree  (hyiDersemia) :  The  skin  is  much  reddened,  very  painful, 
and  slightly  swollen.  These  sj^mptoms  are  due  to  dilatation  of  the 
capillaries,  and  slight  exudation  of  serum  in  the  tissue  of  the  cutis. 
There  is  a  mild  grade  of  inflammation,  in  which  there  is  an  increase 
of  cells  in  the  rete  Malpighii  alone,  which  is  followed,  in  many  cases 
at  least,  by  detachment  of  the  epidermis.     Redness  and  ])ain  occasion- 


D2GREES  OF  BURXS.  287 

ally  last  a  few  hours,  in  other  cases  several  days.     But  it  is  not  neces- 
sary, and  not  at  all  practical,  to  make  several  grades  on  this  account. 

/Second  degree  (formation  of  vesicles) :  Besides  the  symptoms  of 
tho  first  degree,  vesicles  arise  on  the  surface  of  the  skin ;  before  burst- 
ing these  contain  serum,  clear  or  mixed  with  a  little  blood.  These 
vesicles  foi-m  immediately,  or  in  a  few  hours  after  the  reception  of  the 
bum,  and  may  vary  greatly  in  size.  Anatomically  we  find  that  in 
most  of  these  cases  the  horny  layer  is  detached  from  the  mucous  layer 
of  the  epidermis,  so  that  the  fluid  rapidly  escaping  from  the  capilla- 
ries lies  between  these  two  layers,  just  as  results  from  the  action  of  a 
blister.  The  vesicles  rupture  or  are  punctured;  from  the  remaining 
rete  Malpighii  a  new  horny  layer  of  the  epidermis  forms  quickly,  and 
in  six  or  eight  days  the  skin  is  the  same  as  before.  It  may  also  hap- 
pen that  after  remoA'al  of  the  vesicle  the  denuded  portion  of  skin  is 
excessively  painful,  and  for  several  days,  or  even  a  fortnight,  there  may 
be  superficial  suppuration ;  the  pus  finally  dries  to  a  scab,  under  which 
the  new  epidermis  forms.  You  may  induce  this  state  also  artificially 
by  lea\-ing  a  blister  for  a  long  time  on  one  spot.  Here  also  it  is  un- 
necessary to  make  new  grades  of  these  variations,  for  they  only  de- 
pend on  a  little  greater  or  less  destruction  of  the  rete  Malpighii, 
while  the  greater  or  less  pain  corresponds  to  the  amount  of  denuda- 
tion of  the  nerves  in  the  papillae  of  the  skin. 

Third  degree  (formation  of  eschars) :  By  this  term  we  may  desig- 
nate all  those  cases  where  there  is  formation  of  eschars,  i.  e.,  where 
portions  of  the  skin,  and  even  of  the  deeper  soft  parts,  are  destroyed 
by  the  burn.  Of  course,  the  varieties  may  be  very  great,  as  in  one 
case  there  may  be  only  burning  and  charring  of  the  epidermis  and 
papillre,  in  another  death  of  a  portion  of  the  cutis,  in  a  third  charring 
of  the  skin  or  of  an  entire  limb.  In  all  cases  where  the  papillary  laj-er, 
with  the  rete  Malpighii,  is  destroyed,  there  will  be  more  or  less  sup- 
puration, by  which  the  mortified  portion  will  be  detached,  which  of 
course  will  leave  a  granulating  wound,  that  will  follow  the  ordinary 
course  in  healing.  If  only  the  epidermis  and  the  surface  of  the  pa- 
pillae be  charred,  there  is  only  slight  suppuration,  with  rapid  replace- 
ment of  the  epidermic  layer  from  the  remains  of  the  rete  Malpighii. 

From  what  has  been  said,  you  may  understand  how  from  four  to 
seven  or  more  degrees  might  be  formed ;  but,  to  make  the  subject  com- 
prehensible, the  three  degrees  of  redness,  vesicles,  and  eschars,  are 
enough.  In  extensive  burns  we  often  find  these  different  degrees 
combined,  and,  when  the  injured  part  is  covered  with  charred  epider- 
mis and  dirt,  it  is  often  difficult  to  determine  the  degree  at  any  point. 
If  there  be  suppuration,  it  may  be  either  superficial  or  deep ;  occasion- 
ally it  appears  as  if  islands  of  young  cicatricial  tissue  formed  in   the 


288  BURNS  AND  FROST-BITES. 

midst  of  a  granulating  wound,  and  tliis  has  given  rise  to  the  false  idea 
that  the  latter  could  cicatrize  not  only  from  the  edges  but  from  diifer- 
ent  points  in  the  midst  of  the  wound.  But  such  cicatricial  islands 
never  form  where  there  is  total  absence  of  the  papillary  bodies  of  the 
skin,  but  only  from  some  remnants  of  the  rete  Malpighii,  as  may  hap- 
pen in  burns  and  certain  ulcerations  to  be  hereafter  mentioned. 

The  prognosis  for  the  function  of  burnt  parts  may  be  inferred  from 
what  has  been  said.  We  should,  however,  add  that  after  extensive  loss 
of  the  skin,  as  occurs  especially  from  burns  of  the  neck  and  upper  ex- 
tremities by  hot  liquids,  there  is  very  considerable  cicatricial  contrac- 
tion, by  which,  for  instance,  the  head  may  be  completely  drawn  to  one 
side  of  the  neck,  or  anteriorly  to  the  sternum,  or  the  arm  fixed  in  a 
flexed  position  by  a  cicatrix  in  the  bend  of  the  elbow.  In  the  course 
of  time  these  cicatrices  become  more  distensible  and  pliable,  but  rarely 
to  such  an  extent  as  entirely  to  remove  the  disturbance  of  function 
and  the  disfigurement,  so  that  in  many  cases  plastic  operations  are 
necessary  to  imjDrove  these  conditions.  It  was  formerly  asserted  that 
the  cicatrices  after  bums  contracted  more  strongly  than  any  other 
cicatrices.  But  this  is  only  apparently  so,  for  scarcely  any  other  in- 
jury ever  causes  the  loss  of  such  large  portions  of  skin ;  we  may 
readily  perceive  that,  when  this  does  occur  (as  in  plastic  operations 
and  after  extensive  destruction  of  the  skin  by  ulcerations),  the  con- 
traction of  the  cicatrix  is  jvrst  as  great. 

Entirely  apart  from  the  different  degrees  of  burns,  their  extent  is 
of  the  greatest  importance,  as  regards  their  danger  to  life.  It  is  gen- 
erally said  that,  if  two-thirds  of  the  siu-face  of  the  body  be  burned 
only  in  the  first  degTce,  death  soon  occurs,  in  a  manner  that  has  as 
yet  received  no  physiological  ex[3lanation. 

[When  granulating  Avounds  began  to  skin  over  from  the  middle, 
it  was  supposed  that  the  epitlielium  of  the  cicatricial  islands  was 
formed  from  granulations  or  wandering  cells,  and  that  an  epithelial 
matrix  was  not  necessary  for  cicatrization  ;  but  numerous  accurate 
observations  seem  to  show  that  this  view  is  untenable,  and  that  in 
such  cases  the  burn  has  been  of  unequal  depth.  The  papillary 
layer  of  the  skin  has  been  destroyed,  but  at  some  points  the  sweat- 
glands  and  hair-follicles  have  remained  intact  ;  if  the  entire  sur- 
face of  the  wound  now  granulates,  the  epithelial  remnants  are  at 
first  overgrown  and  escape  notice,  but,  as  the  granulations  change 
to  connective  tissue,  they  start  up  as  islands  between  the  granula- 
tions, and  cicatrization  proceeds  from  them  as  from  the  edges.] 

Should  the  burn  not  prove  fatal  from  its  extent  alone,  the  great 
loss  of  skin  and  consequent  suppuration  may  prove  dangerous,  espe- 
cially for  children  and  old  persons  ;  in  the  same  way  the  amputa- 


TREATMENT   OF  BURNS.  289 

tions  necessary  from  complete  charring  of  single  extremities  involve 
certain  dangers,  which  are  the  more  serious  as  they  affect  persons 
already  gi'eatly  depressed  by  the  burn. 

In  the  treatment  of  burns  in  the  first  and  second  degrees,  more 
depends  on  alleviating  the  pain  than  oa  any  energetic  treatment ; 
for  we  cannot  hasten  the  return  of  the  skin  to  its  natural  state,  but 
must  leave  the  course  of  healing  entirely  to  Nature. 

[Immediately  after  an  extensive  burn,  erven  when  it  has  not  been 
deep,  the  patient  is  usually  very  much  excited,  crying  and  moan- 
ing with  pain,  but  when  the  pain  is  alleviated  he  quiets  down,  and 
then  only  wants  to  drink.  Consciousness  is  perfect — the  most 
exact  account  of  the  injury  can  be  given.  In  children  particularly, 
very  soon  after  severe  burns,  there  is  vomiting  of  food  and  bile, 
rarely  of  blood  ;  the  latter  is  almost  always  a  sign  of  fatal  result. 
The  patient  does  not  pass  water,  and  if  a  catheter  be  introduced 
we  find  no  urine,  or  only  a  small  quantity  of  albuminous  or  haemor- 
rhagic  urine.  A  few  hours  after  the  accident  there  is  yawning  and 
deep  sighing  ;  the  patient  gradually  becomes  apathetic  ;  if  he  has 
not  already  vomited,  he  has  eructation  and  hiccough,  and  perhaps 
vomiting.  Then  delirium  begins,  the  patient  tosses  about  regard- 
less of  his  burns,  he  has  clonic  spasms,  sometimes  opisthotonus  ;  he 
becomes  unconscious  ;  the  pulse,  which  just  after  the  injury  was 
frequent  and  small,  becomes  threadlike  and  cannot  be  counted,  the 
respiration  is  hurried  and  superficial,  there  is  cyanosis,  and  the  pa- 
tient dies  in  delirium  or  stupor  a  few  hours  or  one  or  two  days 
after  the  injury.  Very  early  the  bodily  temperature  falls  below 
normal,  and  remains  so  till  death  ;  this  low  temperature  is  of  bad 
prognosis.  In  other  cases  life  lasts  longer  ;  the  patient  appears  to 
revive,  but,  even  after  a  week,  the  above  symptoms  may  come  on 
and  cause  death  very  suddenly. 

The  fatal  result  may  be  due  to  intense  phlogistic  or  septic  poi- 
soning, especially  in  rather  chronic  cases. 

■  Wert/ieim  first  called  attention  to  the  presence  of  jieculiar 
bodies  in  the  blood  of  patients  who  had  been  burned,  which  he 
recognized  as  destroyed  red  blood-corpuscles  ;  hence  he  concluded 
there  was  extensive  destruction  of  the  blood  ;  but  this  view  has 
been  contradicted  by  others.  Ponfich  has  shown  by  experiments 
on  dogs  that  even  in  a  few  minutes  after  reception  of  a  burn  there 
is  a  marked  change  in  the  blood,  a  molecular  disintegration  of  the 
red  corpuscles.  The  haemoglobin  thus  set  free  is  excreted  by  the 
kidneys  and  excites  severe  parenchymatous  nephritis  ;  so  the  ac- 
tual cause  of  death  is  destruction  of  the  red  corpuscles  and  libera- 
tion of  haemoglobin.  Sonnenhurg' s  expei'iments  show  that  death 
20 


290  BURNS  AND   FROST-BITES. 

comino-  very  quickly  after  burns  is  due  to  overheating  of  the  blood 
and  consequent  paralysis  of  the  heart.  If  death  does  not  occur 
at  once,  the  blood-pressure  sinks  from  reflex  paralysis  of  the  ves- 
sels, which,  however,  does  not  take  place  if  the  sj^inal  medulla  has 
been  divided.  In  such  cases,  burns  are  much  better  borne  ;  from 
these  results  Sonnenbnrg  thinks  that  reduced  tone  of  the  vessels  in- 
duced by  abnormal  irritation  of  the  nervous  system  is  the  actual 
cause  of  death  in  extensive  burns.  Another  view,  held  by  Hebra., 
among  others,  is  that  death  after  burns  is  due  to  shock,  that  is,  to 
the  effect  on  the  sensitive  nerves,  and  consequent  reflex  action  on 
the  heart.  We  know  of  no  remedy  for  avoiding  the  impending 
death  from  severe  burns.  Ponfick,  on  theoretical  grounds,  recom- 
mended transfusion  of  healthy  blood  after  removal  of  a  correspond- 
ing quantity  of  the  changed  blood  ;  but  at  present  we  have  not 
enough  evidence  as  to  the  effect  to  come  to  any  decision.  \^Pon- 
JicJc,  as  quoted  in  the  "  Medical  Record  "  from  the  "  Med.  Chir. 
Rundschau,"  1879,  and  the  "  Allg.  Med.  Cent.  Zeitung,"  No.  4, 
1880,  transfuses  by  injecting  defibrinated  blood  into  the  peritoneal 
sac.  It  is  stated  that  this  is  followed  by  very  little  febrile  reaction  ; 
and  that  after  the  operation  the  proportion  of  red  corpuscles  in  the 
blood  of  the  patient  operated  on  is  at  once  increased.  Ponfick 
tried  the  operations  on  animals,  then  on  human  patients  ;  but  the 
translator  does  not  know  of  its  having  been  done  by  any  one  in 
America.]  In  burns  of  the  first  and  second  class  our  first  caro 
should  be  to  relieve  pain  ;  this  is  generally  done  by  covering  the 
burned  skin,  so  as  to  protect  the  exposed  ends  of  the  nerves  from 
the  air. 

If  the  burn  is  very  extensive,  cold  applications  might  reduce 
the  temperature  so  as  to  hasten  collapse  ;  even  when  not  extensive, 
it  is  not  always  well  borne.  In  burns  of  the  first  class  we  may 
simply  sprinkle  on  starch,  flowers  of  zinc,  bicarbonate  of  soda, 
smear  with  oil,  or  apply  mashed  potato,  starch,  etc. ;  the  whole  burn 
may  be  enveloped  in  prepared  or  salicylated  cotton  moderately 
compressed  by  bandages  ;  this  may  be  left  on  till  thrown  off  by 
the  wound,  and  new  layers  applied  over  i't  with  fresh  bandages. 

In  every  case,  but  particularly  where  the  burn  is  deep,  accurate 
antiseptic  treatment  should  be  employed  whenever  possible  ;  not 
only  because  we  thus  avoid  frequent  change  of  dressings,  which  is 
very  painful,  but  elimination  of  the  gangrenous  parts  goes  on  with- 
out much  general  or  local  reaction  ;  the  slough  may  even  be 
detached  without  inflammation,  and  healing  go  on  without  sup- 
puration, if  the  burn  has  not  been  too  extensive.] 

Another  plan  of  treatment  is  with  a  solution  of  nitrate  of  silver, 


TREATMENT   OF  BURNS.  291 

ten  grains  to  the  ounce  of  water  ;  this  is  to  be  painted  over  the 
burnt  part,  and  compresses  wet  with  the  same  to  be  kept  constantly 
applied.  At  first  the  pain  from  the  cauterization  of  the  jiarts  de- 
nuded of  epidermis  is  occasionally  very  great,  but  a  thin  blackish- 
brown  crust  soon  forms,  and  the  pain  then  ceases  entirely.  I  par- 
ticularly recommend  to  you  this  plan  of  treatment  when  all  three 
degrees  of  burns  are  combined. 

In  burns  of  the  third  degree,  if  there  is  only  mortification  of 
the  cutis  (when  this  is  not  charred,  but  burned  by  boiling  water,  it 
generally  becomes  jDerfectly  white),  the  treatment  is  the  same  as 
that  above  given.  Should  it  subsequently  be  desirable  to  hasten 
the  detachment  of  the  eschar,  cataplasms  may  be  employed  to  stim- 
ulate suppuration  ;  in  most  cases,  however,  this  will  be  unnecessary, 
and  the  treatment  by  nitrate  of  silver  may  be  continued  till  the 
eschar  is  completely  detached.  If  large  granulating  sui-faces  re- 
main, especially  on  parts  of  the  surface  that  are  moved  much,  and 
where  the  neighboring  skin  is  not  very  movable,  it  may  take  a  long 
time,  often  months,  for  them  to  heal.  Very  luxuriant  granulations 
form,  and  their  tendency  to  cicatrize  is  always  very  slight.  Of  the 
remedies  already  given  for  promoting  the  healing  of  such  wounds, 
I  particvdarly  recommend  to  you  the  compression  of  the  wound  by 
strips  of  adhesive  plaster,  which  are  of  excellent  service  in  some  of 
these  cases.  In  the  treatment  of  cicatricial  contractions  resulting 
from  these  burns,  compression  of  the  cicatricial  bands  by  adhesive 
plaster  is  one  of  the  most  important  remedies,  and  you  would  al- 
ways do  well  to  try  this  persistently  before  resorting  to  excision  of 
the  cicatrix,  or  to  plastic  operations. 

If,  in  a  burn  of  the  third  degree,  there  has  been  charring  of  a 
limb,  it  may  often  be  advisable  to  amputate  at  once  ;  not  only  be- 
cause the  detachment  of  a  large  part  of  the  body  is  not  free  from 
danger,  but  also  because  the  stumps  thus  left  are  unfit  for  the  ap- 
plication of  an  artificial  limb. 

If  called  to  a  case  where  there  is  a  burn  of  the  greater  part  of 
the  body,  you  must  give  your  whole  attention  to  the  general  condi- 
tion of  the  patient,  and  try  to  prevent  collapse,  by  the  use  of  stimu- 
lants, such  as  wine,  hot  drinks,  hot  baths,  ether,  ammonia,  etc.  Un- 
fortunately, in  most  of  these  cases,  our  efforts  to  preserve  life  are 
in  vain.  Ilehra  praises  the  treatment  of  extensive  burns  by  the 
continued  warm  bath,  which,  under  proper  circumstances,  may  be 
kept  up  for  weeks. 

[Ilebra's  water-bed,  elsewhere  spoken  of,  is  a  bath-tub  contain- 
ing a  frame  suspended  by  chains  ;  the  frame  has  a  covering  on 
which  the  patient  lies,  and  by  means  of  a  windlass  he  can  be  raised 


292  BURNS  AND  FROST-BITES. 

out  of  the  water  and  lowered  again  ;  his  head  rests  on  a  cushion. 
The  bath  is  filled  with  water  at  a  temperature  of  86°,  and  the  pa- 
tient put  in  without  any  dressings  ;  soon  the  temperature  must  be 
raised  to  101°  or  104°,  else  he  will  suffer  from  cold.  The  water  is 
to  be  kept  at  this  temperature,  which  gives  the  patient  great  com- 
fort ;  pain  ceases,  excitement  is  allayed.  The  patient  remains  in 
the  water-bed  day  and  night ;  when  he  wishes  to  pass  water  or 
have  a  movement  from  the  bowels,  he  is  raised  on  the  frame. 
From  severe  burns  patients  die  in  the  bath  as  often  as  under  other 
treatment,  but  they  do  not  suffer  so  much  ;  and  if  the  burn  be  not 
so  extensive  as  to  induce  death  quickly,  the  bath  is  an  excellent 
means  of  treatment,  and  saves  the  patient  much  pain.  He  may, 
without  great  annoyance,  stay  in  the  bath  for  weeks  or  months. 
The  water  protects  the  parts  from  the  air,  prevents  decomposition 
of  the  slough  and  favoi's  its  detachment,  renders  bandages  and 
dressing  unnecessary,  limits  suppuration,  and  hastens  cicatrization. 
Unfortunately,  HebnCs  water-bed,  which  is  also  useful  in  extensive 
gangrenous  wounds  and  ulcers,  and  in  many  skin-diseases,  is  only 
found  in  hospitals  ;  hence,  in  private  practice  we  must  rely  on 
other  modes  of  treatment,  and  especially  on  antiseptic  dressing.] 


Persons  with  delicate  skins,  long  exposed  to  the  swi's  rays,  may 
have  slight  degrees  of  burns  of  the  face  and  neck.  This  is  often 
observed  in  persons  travelling  on  the  mountains.  When  pei'sons, 
especially  women,  who  do  not  usually  pass  the  day  in  the  sun,  travel 
for  several  bright  days  in  summer,  without  carefully  protecting  tlie 
face  and  neck,  the  skin  becomes  red,  swollen,  and  very  painful ; 
after  three  or  four  days  the  skin  dries  to  brown  crusts,  cracks,  and 
peels  off.  In  other  persons,  with  still  more  irritable  skins,  vesicles 
form,  which  subsequently  dry  up,  without,  however,  leaving  any 
cicatrices  (eczema  solare).  Besides  prophylaxis  by  veils,  sun-shades, 
etc.,  it  is  well  to  cover  the  skin  of  such  mountain  travellers  with 
cold  cream  or  glycerine  ;  the  same  remedies  may  also  be  used  in 
developed  sunburn  ;  if  the  burnt  parts  be  very  painful,  we  may 
apply  cold  compresses. 

Here  we  must  also  speak  of  sunstroke,  or  insolation.  In  our  cli- 
mate, this  disease  occurs  almost  exclusively  in  young  soldiers,  who 
have  to  make  fatiguing  marches  in  full  uniform  in  very  hot,  bright 
weather.  There  are  severe  headache,  dizziness,  unconsciousness,  and 
sometimes  death  in  a  few  hours.  In  the  Orient,  especially  in  India, 
this  disease  is  not  rare  among  the  English  soldiers  ;  some  cases  are 
quite  acute,  ending  with  tetanic  spasms  ;  others  begin  with  long  pro- 


FROST-BITES.  293 

dromata,  and  drag  on  with  symptoms  of  severe  headache,  burning 
sldn,  continued  fatigue  and  depression,  palpitation  of  the  heart, 
twitching  of  the  muscles,  etc. ;  even  when  this  state  ends  in  recovery, 
relapses  are  common.  Patients  with  sunstroke  are  to  be  treated  like 
those  with  congestion  of  the  brain.  Cold  aifusions  and  bladders  of 
ice  to  the  head,  rest  in  a  cool  chamber,  purgatives,  leeches  behind  the 
ears,  sinapisms  to  the  nape  of  the  neck,  are  the  proper  remedies.  Ac- 
cording to  tlie  experience  of  English  surgeons,  venesection  is  injuri- 
ous. 


We  also  have  something  to  say  about  the  effect  of  being  struck 
by  lightning.  Probably  all  of  you  have  at  some  time  seen  houses  or 
trees  that  had  been  struck  by  lightning ;  we  usually  see  a  large  rent, 
a  fissure  with  charred  edges.  Men  and  animals  may  also  be  struck 
so  as  to  lose  single  limbs,  but  this  is  not  always  the  case ;  usually 
the  lightning  travels  along  the  body,  in  at  one  place,  out  at  another ; 
the  clothes  are  rent,  or  even  torn  off  and  cast  aside ;  peculiar,  branched, 
zigzag  brownish-red  lines  are  found  on  the  body ;  these  have  been 
regarded  as  representations  of  the  nearest  tree,  or  as  blood  coagulated 
in  the  vessels  and  shining  through ;  both  views  are  incorrect ;  we  do 
not  know  why  the  lightning  runs  this  peculiar  course  on  the  skin.  If 
a  person  be  directly  struck  by  lightning,  he  is  usually  killed  on  the 
spot.  If  the  lightning  strike  in  his  immediate  vicinity,  it  induces 
symptoms  of  commotion  of  the  brain,  paralysis  of  certain  limbs  or  or- 
gans of  special  sense,  and  occasional  extravasations  and  burns.  The 
latter  heal  like  other  burns,  according  to  their  degree  and  extent. 
Paralysis  from  lightning  is  not  usually  of  bad  prognosis ;  the  nervous 
and  muscular  activity  may  return  after  a  longer  or  shorter  time. 

FEOST-BITES. 

We  may  aivide  frost-bites  into  three  grades  analogous  to  those  of 
burns ;  the  first  of  these  is  characterized  by  redness  of  the  skin,  the 
second  by  formation  of  vesicles,  the  third  by  eschars.  The  first  degree 
of  frost-bite  is  quite  well  knowm ;  we  might  regard  the  so-called  dead- 
ness  of  the  fingers  as  its  mildest  form ;  probably  each  of  you  has  some- 
time had  this  in  a  cold  bath,  or  in  winter-time.  The  finger  becomes 
white,  the  skin  wrinkled,  the  sensation  diminished  ;  after  a  time 
these  symptoms  pass  off,  the  skin  becomes  red,  the  finger  swells, 
and  there  is  a  peculiar  itching  and  prickling.  This  increases  the 
more,  the  more  quickly  warmth  follows  the  cold.  The  redness  of 
the  skin  of  this  degree  of  frost-bite  differs  from  that  in  burns,  by 
its  more  bluish-violet  color. 


294 


BURNS  AND   FROST-BITES. 

Fig.  61. 


Traces  of  lightning  (after  Strieker). 

After  a  time,  these  symptoms  subside  and  the  skin  again  be- 
comes normal.  Generally  no  remedies  are  used  in  these  slight 
cases,  but,  very  properly,  patients  are  warned  against  warming  the 
parts  too  rapidly  ;  rubbing  with  snow,  then  gradually  elevating  the 
temperature,  is  recommended.  The  above  symptoms  are  thus  ex- 
plained :  First,  the  capillaries  are  strongly  contracted  by  the  cold, 
and  are  then  paralyzed  for  a  time.     I  shall  not  here  discuss  the 


\ 


FROST-BITES.  295 

tenability  of  this  hypothesis ;  this  explanation  involves  all  the 
difficulties  that  we  have  already  met  in  the  theories  of  inflamma- 
tion. 

[In  some  persons  the  least  cold  causes  contraction,  not  of  the 
capillaries,  but  of  the  arteries,  especially  in  the  fingers,  usually 
only  in  one  or  two  fingers.  Dipping  the  hand  in  cold  water,  even 
in  summer,  or  a  damp  atmosphere,  is  enough  in  some  persons  to 
induce  actual  contraction  of  the  artery  ;  the  finger  looks  like  that 
of  a  corpse  ;  it  is  absolutely  ansemic,  as  if  it  had  an  Esmarcli's  band- 
age applied  ;  pricking  with  a  needle  brings  no  blood  ;  at  the  same 
time  there  is  a  feeling  of  numbness  and  stiffness.  Restoration  of 
the  cii'culation  takes  ten  or  fifteen  minutes  ;  rubbing,  warming, 
etc.,  have  little  effect ;  only  after  dipping  in  hot  water  does  the  cir- 
culation gi-adually  return  ;  the  first  phalanx  reddens  Avhile  the  others 
remain  white  for  a  time.  There  is  no  pain,  and  very  little  para- 
lytic dilatation  of  the  vessels.  The  whole  process  differs  entirely 
from  ordinary  contraction  of  the  capillaries  induced  by  anoeraia 
from  cold,  for  ovlXj  a  certain  vascular  territory,  which  is  always  the 
same,  is  affected. 

In  cases  of  freezing,  if  there  is  formation  of  vesicles,  thei'e  is 
more  danger  than  if  there  is  merely  redness  ;  they  are  often  ac- 
companied by  loss  of  sensation,  and  there  is  danger  of  mortifica- 
tion. Freezing  differs  from  burning  ;  in  the  latter,  gangrene  is  an 
immediate  result ;  it  does  not  extend  subsequently  ;  but  in  freezing, 
the  cold  acts  first  on  the  tissues  and  the  fluid  contained  in  thenT, 
and  it  is  only  when  the  parts  have  thaw^ed  that  the  changes  lead- 
ing to  mortification  show  themselves  ;  so,  at  first,  the  parts  may 
look  normal,  and  there  may  be  some  circulation,  while  the  vitality 
of  the  cells  and  blood  has  been  so  much  affected  that  gangrene  is 
inevitable  ;  but  we  cannot  say  how  far  it  will  extend. 

Blood  that  has  been  frozen  and  thaw^ed  out  is  bright  red,  but 
the  haemoglobin  escapes  from  the  cells  ;  this  blood  has  the  pe- 
culiarity of  causing  coagulation  in  normal  blood,  and  by  injecting 
enough  of  it  into  the  circulation  of  a  living  animal  you  cause  its 
death  from  clots  in  the  heart  and  large  blood-vessels.] 

Recent  investigations  of  Samuel  show  that  after  certain  grades 
of  freezing  there  is  a  true  inflammation  which  goes  on  to  regular 
gangrene.  From  clinical  experience  I  know  that  in  such  cases  there 
is  a  process  not  found  in  burns  ;  for  parts  badly  burned,  even  when 
not  turned  to  cinder,  shrivel  up,  and  the  blood  coagulates  in  the 
vessels,  so  that  other  blood  cannot  enter  them  even  if  they  con- 
tinue to  exist.  If  a  frozen  limb  thaws  for  a  time,  arterial  blood 
may  again  enter  the  vessels,  and  the  question  will  be  whether  the 


296  BURNS  AND  FROST-BITES. 

walls  of  the  vessels  can  still  keejD  the  blood  fluid  and  the  tissues  use 
up  the  blood  coming  to  them.  If  this  be  so,  the  frozen  limb  may 
regain  its  vitality  ;  if  it  does  not,  gangrene  occurs.  In  this  transi- 
tion stage  the  veins  are  much  distended,  and  this  may  facilitate 
thrombosis  in  them,  Bergmann  recommends  particular  attention 
in  the  treatment  of  this  stage  ;  he  has  had  unusually  good  results 
from  vertical  suspension  of  the  limb,  which  favors  the  return  of 
the  venous  blood. 

Redness  following  a  frost-bite  may  sometimes  remain  permanent, 
i.  e.,  the  capillaries  remain  dilated.  This  is  especially  apt  to  occur 
in  frost-bites  of  the  nose  and  cars,  and  is  usually  incurable.  In  Ber- 
lin, I  treated  a  young  man  who  had  a  dark-blue  nose,  as  a  result  of 
frost-bite,  and  wished  at  all  hazards  to  be  relieved  of  the  deformity. 
He  persistently  pursued  the  different  modes  of  treatment ;  first,  he  had 
the  nose  painted  with  collodion,  after  which  it  looked  as  if  varnished, 
and,  as  long  as  the  coating  of  collodion  continued,  it  was  somewhat  paler, 
but  the  improvement  was  not  permanent.  Then  the  nose  was  painted 
with  dilute  nitric  acid,  which  gave  it  a  yellow  tint.  After  detachment 
of  the  epidermis  the  evil  again  appeared  improved  for  a  time  ;  but  it 
soon  returned  to  its  former  state.  Tlien  we  tried  treatment  with 
tincture  of  iodine  and  nitrate  of  silver,  which  for  a  time  gave  tlie  nose 
a  brownish-red,  then  a  brownish-black  color.  The  patient  bore  all 
these  changes  of  color  heroically,  but  the  perverse  capillaries  continued 
dilated,  and  the  nose  remained  bluish  red  at  the  last,  just  as  it  had 
been.  I  still  thought  of  trying  cold,  but  feared  the  condition  might 
be  made  worse,  and,  after  several  months'  treatment,  had  to  tell  the 
hero  of  this  tragi-comical  history  that  I  could  not  cure  him.  The 
treatment  of  chilblains  and  the  consequent  ulcers,  of  which  Ave  shall 
speak  immediately,  may  be  just  as  diflicult. 

Frost-bite,  where,  besides  redness  of  the  skin,  there  is  formation  of 
vesicles,  is  more  severe ;  it  is  often  accompanied  by  complete  loss  of 
sensation  of  the  affected  part,  and  there  is  always  danger  of  mortifica- 
tion. The  formation  of  vesicles  in  frost-bite  is  prognostically  much 
worse  than  it  is  in  burns.  The  serum  contained  in  the  vesicles  is 
rarely  clear,  but  usually  bloody.  A  limb  completely  frozen  is  said  to 
be  perfectly  stiff  and  brittle,  and  small  portions  are  said  to  break  off 
like  glass,  if  carelessly  handled.  I  have  had  no  opportunity  to  verify 
these  statements,  but  remember  that,  when  I  was  a  student,  a  man  was 
was  brought  to  the  Gottingcm  surgical  clinic  with  both  feet  frozen ; 
during  transportation  to  the  hospital,  they  had  become  spontaneously 
detached  at  the  ankle-joint,  so  that  they  hung  only  by  a  couple  of 
tendons.  Double  amputation  of  the  leg  above  the  malleoli  had  to  be 
made.     How  far  a  limb  may  be  entirely  fi-ozen,  so  that  the  circulation 


BURNS   AND  FROST-BITES.  297 

IS  entirely  arrested,  frequently  cannot  be  determined  for  a  time ; 
hence  we  must  not  be  too  hasty  about  amputating.  In  Zurich,  I  had 
two  cases  where  both  feet  were  dark  blue  and  without  feeling,  and 
on  being  punctured  with  a  needle  only  a  drop  of  black  blood  escaped ; 
nevertheless,  the  foot  lived,  and  only  a  few  toes  were  lost.  In  a  third 
case,  in  a  very  debilitated  patient,  where  both  feet  as  high  as  the 
calf  were  dark  blue  and  covered  with  vesicles,  they  became  entirely 
gangrenous.  If  there  be  extensive  gangrene  of  the  skin,  beyond  a 
doubt,  we  should  not  delay  amputating,  for  these  patients  are  very 
subject  to  pyajmia.  A  very  sad  case  occurred  in  the  Zurich  hospital. 
A  powerful  young  man  had  both  hands  and  both  feet  frozen,  so  that 
all  became  gangrenous ;  the  patient  could  not  make  up  his  mind  to  the 
four  amputations,  nor  could  I  bring  myself  to  persuade  him  to  the 
fearful  operation.     Pie  died  of  pj^a^mia. 

The  ends  of  the  extremities,  the  point  of  the  nose,  and  tips  of  the 
ears,  are  most  liable  to  be  frozen.  Closely-fitting  clothes,  which  impede 
the  circulation,  increase  the  predisposition.  Cold  wind,  and  cold  ac- 
companied by  moisture,  induce  frost-bite  more  readily  than  very  great 
still,  dry  cold. 

There  is  also  a  total  freezing  or  stiffening  of  the  whole  body,  in 
which  the  patient  loses  consciousness,  and  falls  into  a  state  of  very 
limited  vitality.  The  radial  pulse  can  hardly  be  felt,  the  heart-beat  is 
scarcely  audible,  the  respiration  almost  imperceptible,  and  the  whole 
body  is  icy  cold.  This  state  may  pass  at  once  into  death ;  then  all 
the  fluids  harden  into  ice.  This  general  freezing  is  especially  apt  to 
occur  when  tlic  individual,  overcome  by  fatigue  and  cold,  lies  down 
while  freezing ;  he  soon  falls  asleep,  and  sometimes  never  wakes 
again.  It  has  never  been  accurately  determined  how  long  a  patient 
may  remain  in  this  stiff  condition,  with  very  slight  appearance  of  life, 
and  again  recover;  we  find  mention  of  the  state  having  lasted  six 
days.  Whether  this  be  true  or  not,  we  should  continue  our  attempts 
at  resuscitation  as  long  as  a  heart-beat  can  be  detected. 

Let  us  commence  the  treatment  of  frost-bite  with  this  state  of 
general  stiffness.  We  must  here  avoid  any  sudden  change  to  higher 
temperature,  but  increase  the  warmth  gradually.  Such  a  patient 
should  be  placed  in  a  cool  chamber,  on  a  cold  bed,  and  frictions  made 
for  several  hours.  At  the  same  time,  artificial  respiration  should  be 
occasionally  tried,  if  the  breathing  becomes  imperceptible.  As  slight 
stimulants  that  may  do  good,  I  would  mention  enemata  of  cold  water, 
4nd  holding  ammonia  to  the  nostrils.  Very  gradually,  as  the  patient 
becomes  conscious,  we  raise  the  surrounding  temperature,  keep  him  for 
a  time  in  a  slightly-warmed  rooin,  and  at  first  give  only  tepid  diinks. 
As  the  differ/mt  parts  of  the  body,  one  by  one,  regain  vitality,  there  is 


298  TREATMENT  OF  FROST-BITE. 

occasionally  some  pain  in  the  limbs,  especially  if  they  \a  ere  wannt;d 
too  rapidly ;  in  these  cases  it  is  well  to  envelop  the  painful  parts  in 
cloths  dipped  in  cold  water.  The  patient  may  remain  for  hours  or 
days  in  a  benumbed,  senseless  condition,  which  disappears  gradually 
Of  late  experiments  have  been  made  in  resuscitating  stiifened  ani- 
mals which  appear  to  show  that  animals  are  more  certainly  saved 
from  death  by  rapid  than  by  slow  warming.  I  should  not  readily  de- 
cide from  these  experiments  on  animals,  to  depart  from  the  rules 
already  empirically  employed  for  treatment  of  persons  frozen  stiff,  and 
which  appear  to  be  correct  for  local  frost-bites,  but  the  question  is 
worth  further  experiment.  Such  cases  of  general  freezing  rarely 
escape  without  loss  of  some  limbs,  or  parts  of  them,  and,  in  regard  to 
the  treatment  of  these  frozen  parts,  I  can  give  you  little  advice.  The 
vesicles  are  punctured  and  evacuated ;  the  feet  or  hands  may  be 
wrapped  in  cold,  wet  cloths ;  then  we  must  wait  to  see  whether  and 
how  extensively  gangrene  will  occur.  If  the  bluish-red  color  passes 
into  a  dark  cherry-red,  the  chances  of  restoration  to  life  are  slight. 
Gangrene  will  occur  in  the  great  majority  of  such  cases.  By  testing 
the  sensibihty  with  a  needle,  and  noting  the  escape  of  blood  from 
these  fine  openings,  we  test  how  far  the  limb  has  ceased  to  live  ;  but 
this  only  becomes  certain  when  the  line  of  demarkation  forms ;  that 
is,  when  the  dead  is  sharply  bounded  from  the  living,  and  inflamma- 
tory redness  develops  on  the  border  of  the  gangrenous  parts.  But 
the  general  condition  may  become  dangerous  before  the  line  of  de- 
markation is  fully  formed ;  hence  amputation  must  not  be  delayed 
too  long  if  the  inflammation  after  freezing  assumes  a  phlegmonous 
character.  The  detachment  of  single  toes  or  fingers  we  may  leave 
to  itself;  but  where  there  is  gangrene  of  a  large  part  of  a  limb, 
amputation  is  decidedly  preferable. 

I  will  here  return  to  chilblains  (perniones),  not  because  they  may 
become  particularly  dangerous,  but  because  they  are  an  exceedingly 
annoying  disease,  and  are  in  some  cases  very  difficult  to  cure,  and  for 
which,  as  good  family  doctors,  you  must  have  a  series  of  remedies. 
Chilblains  are  caused  by  paralysis  of  the  capillaries,  with  serous  exu- 
dation in  the  tissue  of  the  cutis ;  they  are,  as  most  of  you  know, 
bluish-red  swellings  on  the  hands  and  feet,  which  prove  excessively 
annoying  from  their  severe  burning  and  itching,  and  from  the  occa- 
sional formation  of  ulcers.  They  result  from  repeated  slight  freezing 
of  the  same  spot,  and  do  not  occur  with  equal  frequency  in  all  per- 
sons ;  they  are  less  annoying  in  very  cold  weather  than  during  the 
change  from  cold  to  warm.  At  night,  on  going  to  bed,  when  the 
hands  and  feet  become  warm,  the  itching  occasionally  becomes  so 
troublesome  that  the  patient  has  to  scratch  them  for  hours.  In  gen- 
eral, females  are  more  disposed  than  males,  and  young  persons  more 


BURNS  AND  FROST-BITES.  299 

than  old,  to  chilblains.  Employments  requiring  frequent  change  of 
temperature  particularly  predispose  to  them ;  clerks  and  apothecaries, 
who  stay  for  a  time  in  a  warm  room,  then  in  a  cold  cellar  or  ware- 
house, are  frequent  svibjects.  But  no  station  is  exempt ;  people  who 
always  wear  gloves,  and  rarely  go  out  in  winter,  may  be  attacked  as 
well  as  those  who  have  never  worn  gloves.  Among  females,  chlorosis 
and  disturbances  of  menstruation  occasionally  seem  to  predispose  to 
them ;  generally,  frequent  returns  of  frost-bite  appear  to  be  connected 
with  some  constitutional  anomaly. 

As  regards  treatment,  it  is  usually  very  difficult  to  combat  the 
causes  due  to  constitution  and  occupation ;  hence  we  are  chiefly  lim- 
ited to  local  remedies.  In  Italy,  where  the  disease  is  very  frequent, 
if  a  cold  winter  occurs,  frictions  with  snow  and  ice  compresses  are 
recommended.  With  us,  these  are  less  used,  and  do  no  good,  or  at 
most  only  alleviate  the  itching  for  a  time.  Salve  of  white  precipitate 
of  mercury  (one  di'achm  to  the  ounce  of  lard),  frictions  with  fresh 
lemon-juice,  painting  with  nitric  acid  diluted  with  cinnamon-water  (one 
drachm  to  four  ounces),  solution  of  nitrate  of  silver  (ten  grains  to  the 
ounce),  and  tincture  of  catitharides,  are  remedies  that  you  may  resort 
to.  Sometimes  one  answers,  sometimes  another ;  hand  or  foot  baths 
with  muriatic  acid  (about  one  and  a  half  to  two  ounces  to  a  foot-bath, 
use  for  ten  minutes),  and  washing  with  infusion  of  mustard-seed,  are 
also  celebrated.  If  the  chilblains  open  on  the  top,  they  may  be 
di-essed  with  ointment  of  zinc  or  nitrate  of  silver  (gr.  j  to  3  j  fat).  I 
have  here  given  you  only  a  small  number  of  the  remedies  recom- 
mended, the  effect  of  most  of  which  I  have  myself  proved,  although 
there  are  a  number  of  others ;  at  the  commencement  of  your  practice 
you  will  find  these  enough  for  combating  this  common,  trifling  disease. 


CHAPTER  X. 

ACUTE NON-TRAUMATIG  INFLAMMATION  OF  THE 
SOFT  PABTS. 


LECTURE    XXI. 


General  Etiology  of  Acute  Inflammations. — Acute  Inflammation :  1.  Of  tlie  Cutis, 
a,  Erysipelatous  Inflaunnation  ;  5,  Furuncle ;  c,  Carbuncle  (antbrax),  Pustula  Ma- 
ligna. 2.  Of  the  Mucous  Membranes.  3.  Of  tbe  Cellular  Tissue,  Acute  Abscesses. 
4.  Of  the  Muscles.  5.  Of  the  Serous  Membranes,  Sheaths  of  the  Tendons,  and 
Subcutaneous  Mucous  Bursse. 

GENTLEMEiSr :  So  far  we  have  treated  only  of  injuries,  now  we 
shall  pass  to  the  acute  inflammations  which  are  of  non-traumatic 
origin.  Of  these  cases,  those  belong  to  surgery  that  occur  on  the 
outer  part  of  the  body ;  also  those  which,  occurring  in  internal  organs, 
are  still  accessible  to  surgical  treatment.  Although  I  must  start  with 
the  idea  that  you  already  know  the  causes  of  disease  in  general,  it 
Btill  seems  necessary  to  make  some  preliminary  remarks  with  special 
reference  to  the  subject  of  which  we  are  about  to  treat. 

The  causes  of  acute  non-traumatic  inflammations  may  be  divided 
into  about  the  following  categories : 

1.  Mepeated  Mechanical  or  Chemical  Irritation. — At  the  firs+ 
glance,  this  seems  to  come  under  the  head  of  trauma,  but  it  makes 
considerable  difi"erence  whether  such  an  irritation  acts  once  on  a  tissue 
or  whether  it  be  frequently  repeated,  for,  in  the  latter  case,  each  suc- 
ceeding irritation  affects  a  tissue  already  irritated.  An  example  will 
make  this  clear  to  you.  Suppose  a  person  is  rubbed  continuously  by 
a  projecting  sharp  nail  in  his  boot  or  shoe ;  at  first  there  w^ould  be  a 
slight  wound  wuth  circumscribed  inflammation,  but  afterward  the 
inflammation  will  spread  and  become  more  intense  as  long  as  the  irri- 
tation lasts.  Let  us  take  another  example  of  chemical  irritation  :  If 
a  person  not  accustomed  to  highly-seasoned  food  eats  Spanish  pepper 


ACUTE  NON-TRAUMATIC  INFLAIIMATIOX  OF  SOFT  PARTS.       301 

it  would  induce  temporary  hypercemia  and  swelling  of  the  oral  and 
gastric  mucous  membrane ;  should  one  continue  the  use  of  so  acrid  a 
substance  for  a  length  of  time,  he  might  excite  a  severe  gastritis. 
Except  in  cases  of  the  first  example,  these  rapidly-repeated  irritations 
are  not  frequent  in  practice,  but  they  have  a  great  deal  to  do  with  the 
origin  of  chronic  inflammation  ;  when,  of  themselves  insignificant,  the}'" 
act  on  parts  more  or  less  weak.  We  must  again  return  to  this 
point. 

2.  Catching  Cold. — You  all  know  that  by  catching  cold  one  may 
acquire  various  diseases,  especially  acute  catarrh  and  inflammations  of 
the  joints  or  lungs  ;  but  we  do  not  know  what  is  the  particular  inju- 
rious influence  in  catching  cold,  or  what  immediate  changes  it  causes 
in  the  tissues.  The  rapid  change  of  temperature  is  blamed  as  the 
chief  cause  of  catching  cold,  but  by  this  means  we  cannot  experi- 
mentally induce  an  inflammation,  or  any  similar  disease.  One  catches 
cold  from  being  heated,  and  then  being  exposed  to  a  cold  draught  for 
a  length  of  time  ;  by  careful  observation  he  may  say  just  when  he 
caught  cold.  The  cold  may  have  a  purely  local  action ;  for  instance, 
one  sits  for  a  time  at  the  window,  and  the  cold  wind  blows  on  the  side 
of  his  face  toward  the  window  ;  after  a  few  hours  he  is  attacked  by 
paralysis  of  the  facial  nerve.  We  may  here  assume  that  molecular 
changes  have  occui'red  in  the  nerve-substance,  by  which  the  conduct- 
ing power  of  the  nerve  is  lost.  Another  might  get  a  conjunctivitis 
from  the  same  cause.  These  are  purely  local  colds.  Another  case  is 
more  frequent,  viz.,  that  on  catching  cold  that  part  is  attacked  which 
in  the  person  aff"ected  is  most  liable  to  disease,  the  ^^  locus  minoris 
resistefitke.^^  Some  persons,  after  catching  cold  in  any  way,  have 
acute  catarrh  of  the  nose  (snuffles) ;  others  have  gastric  catarrh,  others 
muscular  pains,  and  still  others  have  inflammations  of  the  joints. 
Now,  as  these  parts  are  not  always  directly  afi'ected  by  the  injury  (as 
when  one  has  nasal  catarrh  from  getting  his  feet  wet),  we  must  sup- 
pose that  the  whole  body  is  implicated,  but  the  action  of  the  injury  is 
only  shown  at  the  locus  minoris  resistentice.  Whether  this  transfer 
of  such  injurious  influences  to  a  special  part  of  the  body  is  due  to  the 
nerves,  or  to  the  blood  and  other  fluids  of  the  body,  is  a  question  which 
cannot  at  present  be  decided,  and  about  which  physicians  are  divided 
into  the  two  great  bodies  of  neuropaths  and  hxunoralists.  Reasons 
may  be  adduced  for  both  views.  I  rather  incline  to  the  humoral  view, 
and  regard  it  as  possible  that,  for  instance,  chemical  changes  may 
occur  or  be  prevented  in  the  skin  while  sweating,  which  may  have  a 
poisonous  effect  on  the  blood,  and  may  act  as  an  irritant  now  on  this, 
now  on  that  organ.  According  to  the  old  form  of  speech,  these  in- 
flammations due  to  catching  cold  are  called  "  rheumatic  "  (from  pevfia, 


302  MIASMATIC  INFECTION. 

flow) ;  but  this  expression  is  so  much  misused,  and  has  come  into  such 
disrepute,  that  it  should  not  be  employed  too  often. 

3.  Toxic  and  Miasmatic  Infection. — We  have  already  (page 
169)  stated  that  moist  and  dry,  purulent  and  putrid,  substances 
brought  in  contact  with  a  wound  induce  severe  progressive  inflamma- 
tions, if  they  enter  the  healthy  tissue  immediately  after  the  injury^pr, 
under  certain  previously-mentioned  circumstances,  pass  through  the 
granulations  of  a  wound  into  the  tissue.  It  is  true,  the  body  is 
tolerably  protected  on  its  surface  by  the  epidermis,  on  the  mucous 
coats  by  thick  epithelium,  against  the  entrance  of  such  poisonous  and 
inflammatory  materials,  but  the  protection  is  not  perfect.  There  are 
many  poisonous  substances  which  enter  the  body  through  the  skin  or 
mucous  membrane.  Some  of  them  we  term  poison,  such  as  the  secre- 
tion from  glander-ulcers  in  the  horse,  or  from  the  carbunculous  pus- 
tules in  cattle ;  others  we  only  know  from  their  efi'ects,  from  some 
circumstances  of  their  origin.  There  are  invisible  bodies  which  we 
term  "  miasmatic  poisons,"  or  briefly  "  miasm  "  (jUiacr/xa,  uncleanness)  ; 
it  is  supposed  that  these  miasms  develop  from  decomposing  organic 
bodies.  Some  consider  them  as  gases,  others  as  dust-like  particles, 
others  as  minute  organisms  or  their  germs ;  I  think  that  in  many 
cases  the  latter  is  the  correct  view.  The  action  of  these  poisons 
varies,  inasmuch  as  some  of  them  have  a  direct  phlogistic  action;  in 
others  it  is  more  indirect.  Thus  some  poisons,  as  pus,  cadaveric 
poison,  induce  severe  inflammation  at  the  point  where  they  enter  the 
body  (infectionsatr'mm)  y  others  excite  no  inflammation  at  that  point, 
but  are  imperceptibly  taken  into  the  blood,  and,  although  circulating- 
through  all  the  organs,  only  have  an  inflammatory  effect  on  one  or  a 
few  parts  of  the  body.  These  poisons  are,  to  a  certain  extent,  only 
injurious  to  certain  organs;  they  have  a  "specific"  action.  I  shall 
not  here  speak  of  the  primary  action  of  this  poison  in  transforming 
the  blood.  We  do  not  know  the  chemically  active  constituents  of 
most  of  these  poisons  which  act  specifically  on  one  organ  or  tissue ; 
we  cannot  see  them  circulate,  nor  can  we  always  see  their  effects. 
Hence,  you  may  very  justly  ask  me  how  we  can  express  ourselves 
with  so  much  certainty  on  the  subject.  We  decide  on  the  causes  by 
observing  the  morbid  symptoms,  and.  in  so  doing,  support  ourselves 
mainly  on  their  analogy  to  the  effects  of  jDoisons  intentionally  intro- 
duced into  the  body,  especially  to  those  of  our  most  active  medicines. 
If  we  take  the  group  of  narcotics,  they  all  have  a  more  or  less  be- 
numbing effect,  that  is,  a  paralyzing  effect,  on  the  psychical  fimctions, 
but  they  have  also  the  most  pecuhar  specific  effects.  Belladonna  acts 
on  the  iris,  digitalis  on  the  heart,  opium  on  the  intestinal  canal,  etc. 
VVe  see  the  same  thing  in  other  remedies.     By  repeated  doses  of  can- 


ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.       303 

til  a  rides  we  may  excite  inflammation  of  the  kidneys,  by  mercury  in- 
flammation of  the  oral  mucous  membrane  and  salivary  glands,  etc., 
whether  we  introduce  them  into  the  blood  through  the  stomach,  rec- 
tum, or  skin.  So  also  there  is  an  endless  number  of  known  and 
unknown  organic  septic  poisons,  of  which  many,  if  not  all,  have  also 
a  specific  j^hlogogenous  action.  I  mention  only  one  example  :  if  you 
uiject  putrid  fluid  into  the  blood  of  a  dog,  in  many  cases,  besides  the 
direct  blood  intoxication,  he  will  have  enteritis,  pleuritis,  or  pericar- 
ditis. Must  we  not  here  suppose  that  the  injected  fluid  contains  one 
or  more  matters  which  have  a  specific  inflammatory  efi"ect  on  the 
intestinal  mucous  membrane,  on  the  pleura  and  pericardium  ?  If  we 
know  the  point  of  entrance  of  the  poison,  and  have  some  experience 
of  the  poison  itself,  there  will  rarely  be  much  doubt  about  the  cause 
and  action.  But  how  many  cases  there  may  be  where  neither  exists ! 
I  believe  that  infection  is  a  much  more  frequent  source  of  inflamma- 
tions, especially  in  surgery,  than  has  hitherto  been  suspected. 


I  would  still  make  a  few  general  remarks  about  the  forms  ana 
course  of  non-traumatic  inflammations,  I  have  already  told  you  that 
the  characteristic  of  traumatic  inflammations  is,  that  they  are  limited 
to  the  wounded  part ;  if  they  become  progressive,  it  is  generally 
through  mechanical  or  toxic  (septic)  irritation.  This  would  imply 
that  inflammations  induced  by  mechanical  irritations  and  toxic  actions 
have  a  tendency  to  progress,  or  at  least  to  dift'useness  ;  this  is  true  of 
most  inflammations  resulting  from  catching  cold,  which  attack  either 
a  whole  organ  or  a  large  section  of  one  part  of  the  body.  In  this 
regard,  much  depends  on  the  intensity  of  the  mechanical  irritation, 
and,  in  toxic  inflammations,  on  the  quality  and  quantity  of  the  poison, 
especially  on  its  more  or  less  intense  fermenting  action  on  the  fluids 
permeating  the  tissues.  As  regards  inflammations  due  to  repeated 
mechanical  irritation  and  catching  cold,  we  do  not  always  have  reason 
to  suppose  that  their  products  are  more  irritating  than  those  of  simple 
traumatic  inflammation  ;  but  if,  during  the  latter,  the  afi"ected  part 
be  kept  absolutely  quiet,  and  the  lymphatic  vessels  and  interstices 
between  the  tissues  are  closed  by  the  infiltration  of  the  parts  about 
the  wound,  the  extension  of  the  products  of  inflammation  into  the 
surrounding  parts  is  much  interfered  with.  But  in  repeated  mechan- 
ical irritations  the  tissue  is  not  kept  at  rest,  and  consequently  the 
products  of  inflammation  extend  unimpeded  around  the  irritated  part, 
and  excite  new  inflammation.  In  inflammation  due  to  catching  cold, 
according  to  my  humoral  view,  the  materia  peccans  is  poured  to  a 
whole  organ  or  tissue ;  hence,  these  inflammations  are  mostly  diffuse 


304  ACUTE   INFLAMMATION   OF   THE   CUTIS. 

from  the  commencement.  If,  from  an  existing  point  of  inflammation, 
a  phlogogenous  material  enter  the  blood,  and  thence  specifically  affect 
any  other  organ,  we  call  tliis  secondary  inflammation  "  metastatic." 
But  these  metastatic  inflammations  may  occur  in  another  and  much 
more  evident  manner,  b}'  means  of  a  blood-clot  in  the  veins,  as  we 
shall  show  in  the  section  on  thrombosis,  embolism,  and  phlebitis. 
Non-traumatic  inflammations  may  terminate  in  resolution,  in  firm 
organization  of  the  inflammatory  product,  in  suppuration,  or  in  morti- 
fication. But  we  will  now  cease  treating  this  subject  in  general 
terms,  and  pass  to  the  inflammations  of  the  difl'erent  tissues. 

1.  ACUTE  INFLAMMATION  OF  THE  CUTIS. 

The  simple  forms  of  acute  inflammation  of  the  skin  (spots,  wheals 
papules,  vesicles,  pustules),  which  are  grouped  under  the  common 
name  of  "  acute  exanthemata,"  belong  to  internal  medicine.  Only 
erysipelatous  inflammation,  furuncle,  and  carbuncle,  are  generally 
spoken  of  as  true  primary  inflammations  of  the  cutis.  I  will  here 
remind  you  that  very  frequently  the  skin  is  secondarily  afffected,  from 
inflammation  of  the  subcutaneous  cellular  tissue  and  muscles,  or  even 
of  the  periosteum  or  bones. 

(a.)  Erysipelatous  inflammation  is  located  chiefly  in  the  papillary 
layer  and  in  the  rete  Malpighii.  The  local  symptoms  are  great  red- 
ness and  oedematous  swelling  of  the  skin,  pain  on  being  touched,  and 
subsequent  detachment  of  epidermis  ;  these  are  occasionally  accom- 
panied by  very  high  fever,  out  of  proportion  to  the  extent  of  the  local 
affection.  The  disease  lasts  from  one  day  to  three  or  four  weeks. 
Any  part  of  the  sldn  or  mucous  membranes  may  be  attacked,  but 
idiopathic  erysipelas  is  particularly  frequent  in  the  head  and  face 
Like  the  acute  exanthemata  of  the  skin,  according  to  the  views  cl 
many  pathologists,  erj'sipelas  of  the  head  and  face  should  also  be  re- 
garded as  a  symptomatic  cutaneous  inflammation ;  that  is,  that  the 
local  afi'ection  was  only  one  symptom  of  an  acute  general  disease.  In 
that  case,  surgery  would  have  as  little  to  do  with  erysipelas  as  with 
scarlatina,  measles,  etc. ;  but,  as  it  occurs  especially  in  wounded  per- 
sons, and  particularly  often  around  wounds,  we  must  study  it  more 
attentively.  I  consider  ert/sijjelas  traumaticimi  not  as  a  symptomatic 
inflammation  of  the  skin,  but  as  a  capillary  Ijonphangitis  of  the  skin, 
which  is  always  due  to  infection.  We  shall  treat  of  this  disease  more 
closely  among  the  accidental  traumatic  diseases,  and  content  ourselves 
here  with  having  called  attention  to  its  relationship. 

(b.)  The  furuncle  or  phlegmon  is  a  peculiar  form  of  inflammation 
of  the  skin,  usually  of  typical  comse.      Some  of  you  may  know  U 


ACUTE  NON-TRAUMATIC  INFLAMIJATIOX  OF  SOFT  PARTS.       S05 

from  personal  observation.  First,  a  nodule  as  large  as  a  pea  or  bean 
forms  in  the  skin  ;  it  is  red  and  rather  sensitive.  Soon  a  small  white 
point  forms  at  its  apex,  the  swelling  spreads  around  this  centre,  and 
usually  attains  about  the  size  of  a  dollar ;  sometimes  the  furuncle  re- 
mains quite  small,  about  the  size  of  a  cherry ;  the  larger  it  is,  the 
more  painful  it  becomes,  and  it  may  render  irritable  persons  quite 
feverish.  If  we  let  it  run  its  own  course,  toward  the  fifth  day  the 
central,  white  point,  becomes  loosened  in  the  shape  of  a  plug,  and  pus 
mixed  with  blood  and  detached  shreds  of  tissue  is  evacuated ;  three 
or  four  days  later  suppuration  ceases,  the  swelHng  and  redness  gradu- 
ally disappear,  and  finally  only  a  punctate,  scarcely-visible  cicatrix 
remains. 

We  rarely  have  the  opportunity  of  anatomically  examining  such 
furuncles  in  their  first  stage,  as  they  are  not  a  fatal  disease  ;  but,  from 
what  we  see  of  the  development  and  from  incision,  the  death  of  a 
small  portion  of  skin  (perhaps  of  a  cutaneous  gland)  seems  to  be  the 
starting-point  and  centre  of  an  inflammation,  during  Avhich  the  blood 
finally  stagnates  in  the  dilated  capillaries ;  b}-  infiltration  with  plastic 
matter,  the  tissue  of  the  cutis  partly  turns  to  pus,  partly  becomes 
gangrenous.  The  peculiaritj^  in  all  this  is,  that  such  a  point  of  in- 
flammation should,  as  a  general  rule,  show  no  tendency  to  spread,  but 
should  throughout  remain  circumscribed,  and  terminate  with  the  de- 
tachment of  the  little  plug  above  mentioned. 

There  is  no  doubt  that  in  many  cases  the  cause  of  single  ftiruncles 
is  purely  local.  Some  parts  where  the  secretion  of  the  cutaneous 
glands  is  particularly  strong,  as  the  perinaeum,  axilla,  etc.,  are  espe- 
cially predisposed  to  furuncles  ;  they  are  also  particularly  common 
in  persons  who  have  very  large  sebaceous  glands  and  so-called  pim- 
ples, maggots,  or  comedones.  But  there  are  also  undoubtedly  consti- 
tutional conditions,  diseases  of  the  blood,  which  dispose  to  the  forma- 
tion of  numerous  furuncles  on  various  parts  of  the  body.  This  morbid 
diathesis  is  called  furunculosis  /  should  it  continue  long,  it  may  prove 
very  exhausting ;  the  patients  grow  thin,  and  are  greatly  pulled  down 
by  pain  and  sleepless  nights  ;  children  and  weakly  old  persons  may  die 
of  the  disease.  It  is  very  popular  to  refer  furuncles  to  full-blooded- 
ness  and  fatness  ;  it  is  beheved  that  fatty  food  predisposes  to  them. 
In  my  country  (Pomerania)  they  say  that  persons  who  sufi"er  much 
from  pustules  and  furuncles  have  "bad  blood."  I  should  very  much 
doubt  the  truth  of  the  supposition  that  fatty  food  especially  disposes 
to  luruncles.  You  will  often  find  that  miserable,  atrophic  children,  and 
emaciated,  sickly  people,  are  frequentl}''  attacked  by  furuncle,  and, 
although  the  lack  of  care  of  the  skin  has  something  to  do  with  this, 
it  i?  not  the  sole  cause.  On  the  other  hand,  it  is  also  true  that  well- 
21 


306  FURUNCLE  AND  CARBUNCLE. 

noui'ished  butchers  are  often  attacked  by  furuncles  ;  but  this  may  be 
otherwise  explained,  for  not  un  frequently  it  may  be  found  that  in 
them  the  furuncles  are  due  to  poisoning  by  some  animal  matter ;  we 
should  at  least  always  examine  for  this  cause.  But  I  think  it  is  going 
too  far  to  assume  that  every  furuncle  is  caused  by  infection,  and  is 
always  to  be  regarded  as  one  symptom  of  a  general  suppvu-ative  dia- 
thesis— of  a  pyaemia. 

The  treatment  of  individual  furuncles  is  very  simple.  Attempts 
have  been  made  to  cut  short  the  process,  and  prevent  suppuration,  by 
early  applications  of  ice.  But  this  rarely  succeeds,  and  is  a  very  tire- 
some treatment,  which  is  not  often  popular  with  the  patient.  I  prefer 
hastening  suppuration  by  warm,  moist  compresses,  and,  if  the  furuncle 
does  not  spread  too  much,  to  quietly  await  the  detachment  of  the 
central  plug,  then  to  squeeze  out  the  furuncle,  and  do  nothing  more. 
If  the  furuncle  be  very  large  and  painful,  we  may  make  one  incision,  or 
two  crossing  each  other,  through  the  tumor ;  then  the  natural  course 
of  the  process  is  favored  by  the  escape  of  blood,  and  the  more  rapid 
suppuration. 

General  furunculosis  is  a  difficult  disease  to  treat  successfully,  es- 
pecially if  we  know  little  of  its  cause.  Usually  we  give  quinine, 
mineral  acids,  and  iron,  internally.  Besides  these,  warm  baths  con- 
tinued perse  veringly  are  to  be  recommended.  A  perfectly -regulated 
diet,  especially  nutritious  meats  with  good  wine,  is  also  advisable. 
The  individual  furuncles  are  to  be  treated  as  above  advised. 

(c.)  Garhuncle  and  carhv.ncidoxis  inflammation  {anthrax)  anatom- 
ically resembles  a  group  of  several  furuncles  lying  close  together. 
The  whole  proces-s  is  more  extensive  and  intense,  more  inclined  to 
progress,  so  that  other  parts  may  be  affected  by  the  extension  of  the  in- 
flammation. Many  carbuncles,  like  most  boils,  are  originally  a  purely 
local  disease.  Their  chief  seat  is  the  hard  skin  of  the  back,  especially 
in  elderly  persons.  Their  origin  and  first  stage  are  the  same  as  in 
furuncle.  But  soon  a  number  of  white  points  form  near  each  other, 
and  the  swelling,  redness,  and  pain,  in  the  periphery,  increase  in 
some  cases  so  much  that  the  carbuncle  may  attain  the  size  of  a  soup- 
dish  ;  and,  while  the  detachment  of  the  white  plugs  of  skin  goes  on 
in  the  centre,  the  process  not  unfrequently  extends  in  the  periphery. 
The  detachment  of  gangrenous  shreds  is  much  greater  in  carbuncle 
than  in  furuncle.  After  the  loss  of  the  plugs  of  cutis,  the  skin  ap- 
pears perforated  like  a  sieve,  but  subsequently  not  unfrequently  sup- 
purates, so  that  after  a  carbuncle  a  large  cicatrix  is  always  left.  But, 
even  when  most  intense,  the  process  is  almost  always  limited  to  the 
skin  and  subcutaneous  cellular  tissue  ;  it  is  most  rare  for  fasciae  and 
muscles  to  be  destroyed,  so  that,  when  a  large  carbuncle  is  in  the 


ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.       307 

vicinity  of  an  artery,  the  danger  of  destruction  of  the  arterial  walla 
IS  more  apparent  than  real,  as  is  shown  by  experience.  After  the  ex- 
tensive throwing  off  of  the  cellular  tissue,  and  the  final  arrest  of  the 
process  in  the  periphery,  healthy  and  usually  very  luxuriant  granula- 
tions develop ;  healing  goes  on  in  the  usual  manner,  and  is  accom- 
plished in  a  time  corresponding  to  the  size  of  the  granulating  surface. 

You  Avill  have  already  noticed  that  the  process  of  formation  of 
fiuruncles  and  carbuncles  differs  from  the  inflammations  with  which 
you  are  already  acquainted,  by  the  constant  and  peculiar  death 
of  portions  of  skin ;  and  I  have  mentioned  that  this  gangrene  of  the 
skin,  at  first  very  small,  is  the  primary  and  local  cause  of  furuncles 
and  carbuncles.  Of  course,  this  must  be  induced  by  an  early,  per- 
haps primary,  occlusion  of  small  arteries,  possibly  of  the  vascular 
net-work  around  the  sebaceous  glands,  without  our  knowing  on  what 
final  cause  this  latter  depends. 

The  course  of  the  ordinary  carbuncle  on  the  back  is  tedious  and 
painful,  although  it  rarely  causes  death.  But  there  are  cases,  especially 
when  the  carbuncle  or  a  difi'use  carbunculous  inflammation  occurs  in 
the  face  or  head,  which  are  accompanied  by  high  fever  and  septic  or, 
as  was  formerly  said,  "  typhous  "  symptoms,  and  which  prove  danger- 
ous and  are  even  generally  fatal  (carbunculus  maligna,  pustula  malig- 
na). All  carbuncles  of  the  face  are  not  of  this  malignant  character; 
some  run  the  usual  course,  and  only  leave  a  disfiguring  cicatrix ;  but, 
as  it  is  difficult  and  often  impossible  to  tell  how  the  case  will  turn 
out,  I  would  advise  you  always  to  be  very  careful  about  the  progno- 
sis. Unfortunately,  I  have  had  such  sad  experience  in  these  carbun- 
cles of  the  face,  that  in  any  affection  of  the  kind  I  am  very  solicitous 
about  the  life  of  the  patient.  Let  me  briefly  narrate  a  case  or  two. 
In  a  young,  strong,  healthy  man,  on  a  journey  to  Berlin,  from  some 
unknown  cause  a  painful  swelling  began  in  the  lower  lip ;  it  increased 
rapidly,  and  soon  spread  to  the  whole  lip,  while  the  patient  became 
very  feverish.  The  surgeon  Avho  was  called  applied  cataplasms,  and 
apparently  undervalued  the  condition  of  the  patient,  as  he  did  not  see 
him  for  two  days.  The  third  day  the  face  was  greatly  swollen  and 
the  patient  had  a  severe  chill,  and  was  quite  delirious  when  brougl\t 
to  the  clinic.  I  found  the  Hp  dark  bluish-red  with  numerous  white  gan 
grenous  patches  in  the  skin.  Several  incisions  were  made  at  once,  tl  e 
wounds  were  dressed  with  chlorine-water,  cataplasms  applied,  and  a 
bladder  of  ice  placed  on  the  head,  as  meningitis  was  beginning.  As 
soon  as  I  saw  the  patient,  I  declared  his  condition  hopeless  ;  he  soon 
feU  into  a  deep  stupor,  and  died  twenty-four  hours  later,  four  days 
after  the  commencement  of  the  carbuncle  on  the  lower  lip.  Unfor- 
tunately, an  autopsy  was  refused.     I  will  mention  another  case  :    A 


308  CARBUNCLE. 

Student  in  Zurich  received  a  sword-cut  on  the  left  side  of  the  head. 
The  wound  healed  without  any  remarkable  symptoms ;  but  it  was  a 
long  while  before  it  closed  entirely.-  For  some  time  there  was  a 
small,  open  wound,  which  was  so  slight  that  the  patient  paid  no  at- 
tention to  it.  Violent  straining  while  fencing,'  and  perhaps  subse- 
quently catching  cold,  may  have  been  the  causes  of  the  following 
catastrophe.  One  morning  the  young  man  awakened  with  consid- 
erable pain  in  the  cicatrix,  and  a  general  feeling  of  illness ;  a  rosy 
redness  and  moderate  swelling  of  the  scalp  rendered  an  attack  of 
simple  erysipelas  ca})itis  probable.  But  the  fever  increased  in  an 
unusual  manner,  without  the  redness  spreading  over  the  head.  The 
patient  had  a  chill,  and  became  delirious.  When  on  the  third  daj'-  he 
was  brought  to  the  hospital,  in  the  vicinity  of  the  cicatrix  I  found  a 
number  of  small  white  spots,  which  showed  me  at  once  that  there 
was  carbunculous  inflammation ;  as  the  patient  was  entirely  uncon- 
scious, and  for  several  reasons  there  Avas  probably  inflammation  of  the 
meninges  of  the  brain,  I  had  little  hope  of  a  cure ;  I  gave  the  ne- 
cessary directions,  but  the  next  day  the  patient  was  dead.  The 
autopsy  showed  various  white  gangrenous  points  in  the  inflamed  scalp 
cicatrix  ;  on  seeking  furtlier,  the  neighboring  veins  were  found  plugged 
with  clots,  and  along  them  the  cellular  tissue  was  swollen  and  con- 
tained points  of  pus.  Anteriorly  I  could  follow  this  condition  of  the 
veins  as  far  as  the  orbit,  but  did  not  try  to  follow  it  farther,  not  wish- 
ing to  injure  the  eye.  After  opening  the  skull,  as  soon  as  the  brain 
was  removed,  we  found  in  the  left  anterior  cranial  fossa  a  moderately 
inflamed  spot  about  as  large  as  a  dollar ;  the  disease  affected  both  the 
dura  and  jDia  mater,  and  even  entered  the  brain-substance.  There 
was  no  doubt  that  the  inflammation  starting  from  the  cicatrix  on  the 
head  had  travelled  along  a  vein  into  the  cellular  tissue  of  the  orbit, 
and  thence  through  the  optic  foramen  and  superior  orbital  fissure  into 
the  skull. 

In  many  cases  of  malignant  carbuncle  of  the  face,  on  careful  ex- 
amination Ave  shall  find  such  an  extension  of  the  inflammation  to  the 
cranial  cavity,  and  consequent  disease  of  the  brain.  But  I  must  re- 
mind you  that  the  extent  of  this  inflammation  as  found  in  the  cadaver 
is  not  at  all  in  proportion  to  the  severity  of  the  constitutional  symp- 
toms, so  that  the  latter  are  by  no  means  fully  explained  by  the  jiP05^ 
mortem  appearances.  Indeed,  there  are  cases,  and  just  the  most 
quickly  fatal  ones,  where  death  occurs  without  our  being  able  to  find 
any  disease  in  the  brain.  Here  there  is  full  room  for  hypothesis  ;  in 
the  rapid,  violent  course  and  the  quick  change  of  carbunculous  in- 
flammation to  gangrene  we  suspect  a  rapidlj'-occurring  decomposition 
of  the  blood,  of  which  the  carbuncle  itself  may  be  either  the  cause  or 


ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.       309 

result.  But,  as  the  decomposition  of  the  blood  must  have  its  cause, 
it  has  been  supposed  that  an  insect  which  has  alighted  on  some  car- 
rion, or  on  the  nose  of  a  horse  with  glanders,  or  a  cow  with  carbun- 
cle, etc.,  lights  soon  after  on  a  man  and  infects  him ;  you  will  here- 
after learn  that  malignant  carbuncles  result  particularly  from  carbun 
culous  cattle.  I  know  of  no  cases  where  this  has  been  actually 
observed,  but  I  do  not  consider  it  impossible  in  certain  cases ;  this 
supposition  is  supported  by  the  fact  that  these  carbuncles  are  most 
frequent  on  parts  of  the  body  which  are  usually  exposed.  At  all 
events,  the  high  fever  and  fatal  blood-infection  are  mostly  results  of 
the  local  disease ;  hence,  we  must  suppose  that  in  these  carbuncles, 
under  circumstances  which  we  do  not  exactly  understand,  peculiarly 
intense  poisons  are  formed,  whose  reabsorption  into  the  blood  causes 
death.  But  the  causes  of  malignant  carbuncle  are  in  most  cases  en- 
tirely obscvue.  In  diabetes  mellitus  and  urjBmia  carbuncle  occurs, 
just  as  sugar  is  observed  in  the  urine  of  persons  otherwise  healthy, 
who  have  furuncles  and  carbuncles ;  these  are  enigmatical  facts.  For- 
tunately, carbuncles  are  not  fi-equent ;  even  simple  benignant  carbun- 
cles are  so  rare  that  in  the  extensive  surgical  policlinic  of  Berlin, 
where  every  year  five  or  six  thousand  patients  presented  themselves, 
I  only  saw  a  carbuncle  once  in  two  years  or  so.  In  Zurich  also  they 
were  rare.  The  diagnosis  of  ordinary  carbuncle  is  not  difficult,  espe- 
cially after  you  have  seen  one ;  diffuse  carbunculous  inflammation  can 
only  be  recognized  after  a  period  of  observation  ;  at  first  it  resembles 
erysipelas. 

The  treatment  of  carbuncle  must  be  very  energetic,  if  we  would 
prevent  the  advance  of  the  disease.  As  in  all  inflammations  disposed 
to  gangrene,  numerous  incisions  should  be  made  early,  to  permit  the 
escape  of  the  decomposed,  putrid  tissues  and  fluids.  Hence  in  every 
carbuncle  you  make  large  crucial  incisions,  dividing  the  whole  thick- 
ness of  the  cutis,  and  long  enough  to  divide  the  infected  skin  clear 
through  to  the  healthy.  If  this  does  not  suffice,  you  add  a  few  other 
incisions,  especially  where  from  the  white  points  you  recognize  gan- 
grene of  the  skin.  The  bleeding  from  these  incisions  is  proportion- 
ately slight,  as  the  blood  is  coagulated  in  most  of  the  vessels  of  the 
carbuncle.  In  the  incisions  you  place  charpie  wet  with  chlorine-water, 
and  renew  it  every  two  or  three  hours ;  over  this  warm  cataplasms 
may  be  regularly  applied  to  hasten  suppiu-ation  by  the  moist  Avarmth. 
If  the  continueci  wamith  be  not  well  borne,  as  in  carbuncle  of  the 
neck,  where  it  may  induce  cerebral  congestion,  the  cataplasms  may  be 
omitted  and  the  antiseptic  dressings  continued  alone,  or  even  cold 
may  be  resorted  to.  If  the  tissue  begins  to  detach,  you  daily  pick  oflf 
the  half-loose  tags  with  the  forceps,  and  so  try  to  keep  the  wound  as 


310       ACUTE   INFLAMMATIONS   OF   THE   MUCOUS   MEMBRANES. 

clean  as  possible.  Strong  granulations  will  soon  appear  here  and 
there ;  finally,  the  last  shreds  are  detached  and  a  honeycombed  granu- 
lating surface  is  left ;  this  soon  smooths  off,  and  subsequently  cica- 
trizes in  the  usual  manner,  so  that  it  only  requires  a  little  occasional 
stimulation  from  nitrate  of  silver,  like  other  granulating  surface.  In 
malignant  carbuncle  the  local  treatment  is  the  same  that  we  have  just 
described.  For  the  rapidly-occurring  cerebral  disease  the  only  thing 
we  can  do  is  to  apply  ice  to  the  head.  Internally  we  usually  give 
quinine,  acids,  and  other  antiseptic  remedies.  But  I  must  acknowl- 
edge that  the  results  of  this  treatment  are  very  slight,  for  in  my  own 
experience  I  do  not  know  a  case  where  it  has  succeeded  in  averting 
death  when  septicaemia  was  at  all  developed  ;  this  is  the  more  depress- 
ing, because  these  malignant  carbuncles  generally  attack  young,  strong 
individuals.  E^^en  if  the  course  be  favorable  as  regards  life,  there  will 
be  considerable  loss  of  skin  and  great  disfigurement,  especially  in  car- 
bunculous  inflammation  of  the  eyelids  or  lips,  as  they  are  mostly  de- 
stroyed by  gangrene.  Early  incision,  excision,  and  burning  out  of 
the  carbuncle,  also  have  little  effect  on  the  fvurther  course  of  the  dis- 
ease, as  I  have  proved  to  myself  in  a  few  malignant  cases.  But  do 
not  be  deterred,  by  these  hopeless  views  of  treatment,  from  making 
early  incisions,  for  cases  occur  where  carbuncles  on  the  face  run  the 
usual  course  after  commencing  with  high  fever.  French  surgeons 
have  attained  some  good  results  by  early  burning  out  the  malignant 
pustule. 

2.  ACUTE  INFLAMMATIONS  OF  THE  MUCOUS  MEMBRANES. 

While  traumatic  inflammation  of  the  mucous  membranes  presents 
nothing  peculiar,  "  acute  catarrh  "  or  "  acute  catarrhal  inflammation  '* 
of  these  membranes  is  a  pecuhar  form  of  disease  which  is  anatomically 
characterized  by  great  hyperaemia,  oedematous  swelling  and  free  secre- 
tion of  a  fluid  at  first  serous  and  subsequently  muco-purulent,  and  is  most 
frequently  caused  by  catching  cold  or  by  infection.  "  Blennorrhcea  " 
is  an  increase  of  catarrh  to  such  a  degree  that  quantities  of  pure  pus 
are  secreted.  Catarrh  and  blennorrhoea  may  become  chronic.  Simple 
observation  of  exposed  mucous  membranes  affected  with  catarrh 
shows  that  it  may  be  very  severe  and  long  continued,  without  the 
substance  of  the  membrane  suffering  much ;  the  surface  of  the  mem- 
brane is  hyper^emic  and  swollen,  somewhat  thick  and  puffy ;  in  rare 
cases  there  are  superficial  loss  of  epithehum  and  small  defects  of  sub- 
stance (catarrhal  ulcers),  but  it  is  only  in  very  rare  cases  that  these 
cause  more  extensive  destruction.  This  observation  is  supported  by 
post-mortem  examination  and  histological  investigation.  The  opinion 
now  is,  that  there  is  only  a  rapid  throwing  off  of  the  epithelial  cells 


ACUTE  NON-TRAUMATIC  INFLAMMxVTION  OF  SOFT  PARTS.       311 

wliich  approach  the  surface  as  pus-cells,  and  that  the  connective-tis- 
sue  layer  of  the  mucous  membrane  takes  no  part  in  the  process.  Al- 
though many  attempts  have  been  made  to  find  segregation  of  the 
cells  in  the  deeper  epithelial  layers  of  mucous  membranes  affected  with 
catarrh,  they  were  unsuccessful  till  Bemak,  Buhl,  and  Mindfleisch, 
discovered  large  mother-cells  in  the  epithelial  layers  of  such  mem- 
branes. 

Pig.  62. 


Epithelial  layer  of  a  conjunctiva  affected  with  catarrh  (after  Rindjleisch).     Magiiified  400  diam 

eters. 

It  was  most  natural  to  explain  this  observation  by  assuming  tliat 
the  mother-cells  were  formed  by  endogenous  segregation  of  the  pro- 
toplasm, and  subsequently  turned  out  their  broods  (as  pus-cells). 
Since,  in  opposition  to  this  view,  it  was  repeatedly  shown  that,  if 
this  were  the  case,  the  mother-cells  should  always  be  found  on  catar- 
rhal mucous  membranes,  while  they  were  found  only  at  first  and 
then  in  small  numbers,  of  late,  they  have  been  explained  quite  dif- 
ferently. Steudener  and  Volkmann  first  advanced  the  idea  that  the 
young  cells  do  not  form  in  the  older  ones,  but  that,  under  certain  me- 
chanically favorable  influences,  the  latter  may  enter  from  without,  but 
have  nothing  to  do  with  the  origin  of  the  catarrh.  Although  this 
view  is  very  difficult  to  prove,  after  much  consideration  and  weigliing 
of  known  facts,  I  consider  it  as  very  probable.  This  is  not  the  place 
to  go  into  details  on  the  matter,  but,  since  it  has  been  proved  by  the 
cinnabar  method  that  the  white  blood-cells  escape  from  the  vessels  of 
the  inflamed  mucous  membrane,  and  not  only  wander  between  the 
epithelium,  but  are  also  found  as  pus-cells  in  the  catarrhal  secretion 
I  should  think  catarrhal  pus  had  the  same  origin  as  other  pus,  viz. 
that  it  came  directly  from  the  blood.  Besides  catarrhal  inflammation, 
mucous  membranes  are  also  subject  to  croupous  and  diphtheritic  in- 
flammations. When,  in  inflammation  of  a  mucous  membrane,  the  prod* 
acts  of  inflammation   (cells  and  transudation)  appearing  on  the  sur 


312 


PHLEGMONOUS   INFLAMMATION. 


face  form  fibrine,  and  thus  become  a  membrane  clinging  to  the  surface^ 
which  after  a  time  dissolves  into  mucus  and  pus,  or  is  lifted  up  by 
pus  which  is  produced  behind  it  from  the  mucous  membrane,  we  call 
it  a  "  croupous  inflammation ;  "  the  mucous  membrane  and  its  epithe- 
lium meantime  remain  intact,  the  parts  are  perfectly  restored.  Diph- 
theria is  exactly  similar  to  the  above  process,  but  the  fibrinous  layer 
is  not  onlv  attached  more  firmly  to  the  tissue,  but  the  serum  per- 
meating the  substance  of  the  membrane  coagulates ;  the  circulation  is 
thus  impaired  so  much  that  occasionally  the  affected  part  becomes  en- 
tirely gangrenous.  In  diphtheria,  the  disintegration  and  gangrene 
are  prominent  symptoms  ;  they  probably  depend  on  very  rapid  devel- 
opment of  germs  of  fungi  and  infusoria  in  the  diphtheritic  membrane. 
Whether  these  fungous  germs  are,  as  many  suppose,  the  cause  of 
diphtheria,  at  present  remains  doubtful.  The  general  affection,  the 
fever,  may  be  very  severe  in  extensive  croupous  inflammation  {as  in 
the  fine  bronchi  and  alveoli  of  the  lungs,  croupous  pneumonia),  but  in 
diphtheria  it  is  of  a  more  septic  character ;  the  latter  disease  is  far 
the  most  malignant.  The  mucous  membrane  of  the  phar^^nx  and 
trachea  is  often  exposed  to  both  forms  of  the  disease.  Catarrhal  con- 
junctivitis, "whL;h  is  so  very  common,  may  become  diphtheritic,  but 
rarely  becomes  croupous.  The  mucous  membrane  of  the  intestinal 
canal  is  seldom  the  seat  of  these  diseases,  the  same  is  true  of  the  mu- 
cous membrane  of  the  genitals,  which  are  so  often  affected  with  con- 
tagious blennorrhoea  (clap,  gonorrhoea). 


B.  ACUTE  INFLAMMATION  OF  THE  CELLULAE  TISSUE. 

INFLAMMATION. 


PHLEGMONOUS 


This  term  is  pleonastic,  for  17  {pXeyfiovT]  means  inflammation,  but 
practically  it  is  so  exclusively  applied  to  inflammation  of  the  cel- 
lular tissue  tending  to  suppuration,  that  every  surgeon  knows  what 
it  means;  another  name  for  the  same  disease  is  pseudo-eri/s?'pe- 
las  ;  it  is  just  as  much  used,  but  seems  to  me  less  distinctive.  The 
causes  of  this  inflammation  are  in  many  cases  very  obscure ;  a  severe 
cold  can  rarely  be  proved  to  be  the  cause ;  frequently  these  in- 
flammations might  result  from  infection,  even  if  the  cutis  be  unin- 
jured, but  this  is  only  hj'pothesis ;  we  have  already  seen  these  pro- 
gressive acute  inflammations  as  a  complication  in  injuries,  especially 
as  a  result  of  local  infection  from  mortifying  shreds  of  tissue  in  con- 
tusions and  contused  wounds.  Spontaneous  inflammation  of  the  cel- 
lular tissue  is  most  frequent  in  the  extremities,  more  frequent  above 
than  below  the  fascise,  especially  prone  to  affect  the  fingers  and  hand ; 
here  it  is  called  panaritium  (corrupted  from  paronychia,  inflammation 
aromid  the  nail,  from  ovv^  nail),  and  to  distinguish  it  from  deepei 


ACUTE  NOX-TRAUMATIC  INFLA5IMATI0X  OF  SOFT  PARTS.       313 

inflammations  also  occurrirjg  in  tlie  fingers  and  hand,  panaritium  sub- 
cutaneum.  If  the  inflammation  aifect  the  vicinity  of  the  nail,  or  the 
nail-bed  itself,  it  is  termed  panaritium  sub  ungue.  Let  us  first  con- 
sider the  sjmi^toms  of  phlegmon  of  the  forearm  :  it  begins  with 
pain,  swelling,  and  redness  of  the  skin,  and  usually  with  high  fever : 
the  skin  of  the  arm  is  somewhat  oedematous  and  very  tense.  With 
this  commencement,  which  always  announces  an  acute  inflammation 
of  the  arm,  its  seat  may  vary  greatly,  and  in  the  first  day  or  two  you 
may  be  unable  to  decide  whether  it  is  a  case  of  inflammation  of  the 
subcutaneous  cellular  tissue,  of  perimuscular  inflammation  below  the 
fascia,  or  even  of  periostitis  or  ostitis.  The  greater  the  oedema,  the 
more  considerable  the  pain,  the  less  the  redness  of  skin,  and  the  less 
intense  the  fever,  the  more  probably  you  have  to  anticipate  a  deep- 
seated  inflammation  which  Avill  terminate  in  suppuration.  If  the  in- 
flammation attacks  only  the  subcutaneous  cellular  tissue,  and  goes  on 
to  suppuration,  as  it  does  in  most  cases  (though  resolution  is  seen), 
this  evinces  itself  in  a  few  days  by  the  skin  becoming  red  at  some 
point,  and  distinct  fluctuation  occurring.  Then  the  pus  either  per- 
forates spontaneously,  or  is  let  out  by  an  incision.  If  the  inflamma- 
tion afiect  parts  of  the  body  where  the  skin,  and  especially  the  epi- 
dermis, is  particularly  thick,  as  in  the  hands  and  feet,  there  is  at  first 
little  i^erceptible  redness,  as  it  Avould  be  hidden  by  the  thick  layer  of 
epidermis.  Pain,  and  a  peculiar  tension  and  throbbing  in  the  inflamed 
part,  announce  the  formation  of  pus  under  the  skin. 

In  some  of  these  cases  a  portion  of  the  skin  becomes  gangrenous, 
the  circulation  being  disturbed  by  the  tension  of  the  tissue,  part  of 
the  skin  loses  its  vitality.  The  fascias  also  are  occasionally  threat- 
ened by  these  inflammations ;  in  such  cases  they  come  through  the 
openings  of  the  cutis  as  large,  white,  consistent,  thready  tags.  This 
is  particularly  the  case  in  inflammations  of  the  scalp,  which  not  un 
frequently  extend  over  the  entire  skull ;  the  whole  galea  aponeurotica 
may  thus  be  lost. 

Let  us  now  pass  to  the  more  minute  anatomical  changes  that  take 
place  in  acute  inflammation  of  the  cellular  tissue ;  we  shall  not  here 
return  to  the  dispute  as  to  whether  vessels,  tissues,  or  nerves,  are  first 
affected,  but  shall  only  speak  of  what  we  can  find  on  direct  anatomical 
examination.  A  series  of  observations  on  the  cadaver,  where  in  various 
cases  we  see  inflammation  in  different  stages,  gives  us  sufficient  infor- 
mation on  this  subject.  The  first  things  we  find  are  distention  of  the 
capillaries  and  swelling  of  the  tissue  by  serous  exudation  from  the 
vessels,  and  a  rich,  plastic  infiltration,  varying  with  the  stage,  i.  e., 
the  connective  tissue  is  filled  with  quantities  of  young,  round  cells. 
This,  then,  is  the  anatomical  condition  of  the  cellular  tissue  under  the 


314 


PHLEGMONOUS   INFLAMMATION. 


cedematous,  reddened,  painful  skin;  subsequently  the  collection  of 
cells  in  the  inflamed  connective  tissue  and  fat  becomes  more  promi- 
nent. These  tissues  become  tense,  and  there  is  stagnation  of  blood 
in  the  vessels  at  various  points,  especially  in  the  capillaries  and  veins ; 
at  some  places  the  circulation  ceases  entirely.  This  stagnation  of  the 
blood,  which  at  first  causes  a  dark-blue  color,  and  then  vehiteness  from 
the  rapid  discoloration  of  the  red  blood-cells,  may  extend  so  far  as  to 
cause  extensive  gangrene  of  the  tissue,  a  result  which  we  have  already 
mentioned.  But  in  most  cases  this  does  not  occur,  but  while  the  cells 
increase,  the  fibrillar  intercellular  substance  disappears,  partly  by  the 
death  of  small  tags  and  particles,  partly  by  gradually  becoming  gelat- 
inous, and  finally  changing  to  fluid  pus. 

Fig.  68. 


)<i^;^^^">y/^^^^^=^ 


Tissue  from  a  prepuce  infiltrated  from  inflammation.  The  fllamcnt.iry  fibrillar  formation  of  the  tissue 
has  entirely  disappeared,  from  the  softening:  influence  of  the  cellular  inflammation.  The  walls  of 
the  vessels"  are  relaxed  and  perforated.    Magnified  about  600. 

As  the  inflammation  progresses  the  entire  inflamed  part  is  finally 
changed  to  pus,  that  is,  to  fluid  tissue,  consisting  of  cells  with  some 
serous  intercellular  fluid  which  is  mixed  with  shreds  of  dead  tissue. 
If  the  process  goes  on  in  the  subcutaneous  cellular  tissue,  extending 
in  all  directions  (most  rapidly  where  the  tissue  is  most  vascular  and 
richest  in  cells),  the  purulent  destruction  of  tissue  or  suppuration 
will  extend  to  the  cutis  from  within,  perforate  it  at  some  point,  and 
through  this  perforation  the  pus  will  escape  outwardly;  when  this 
occurs,  the  process  often  ceases  to  extend.  The  tissue  surrounding 
the  purulent  collection  is  filled  with  cells  and  very  vascular ;  anatomi- 
cally it  closely  resembles  a  granulating  surface  (without  any  distinct 
granulations)  hnlng  the  whole  cavity.    When  the  pus  is  all  evacuated 


ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.      315 

tbe  walls  come  together  and  usually  unite  qioickly.  The  plastic  infil- 
tration continues  for  a  time,  causing  the  skin  to  remain  firmer  and 
more  rigid  than  usual.  But,  by  disintegration  and  reabsorption  of  the 
infiltrating  cells,  and  transformation  of  the  connective-tissue  substance, 
this  state  also  returns  to  the  normal. 

You  will  readily  perceive  that,  anatomically,  the  process  is  much 
the  same  whether  it  be  difi'use  or  circumscribed  ;  the  finer  changes  of 
tissue  in  the  two  are  just  the  same.  But  in  practice  we  distinguish 
between  purulent  hi/iltration  and  abscess.  The  first  expression  ex- 
plains itself:  by  an  abscess  we  usually  understand  a  circumscribed 
collection  of  pus,  excluding  further  progress  of  the  inflammation ; 
those  forming  rapidly,  from  acute  inflammation,  are  called  acute  or 
hot  abscesses,  in  contradistinction  to  cold  abscesses,  or  those  due  to 
chronic  inflammation.  The  following  figure  (Fig.  64)  may  render  the 
formation  of  abscess  more  clear  to  you. 

You  here  see  how  the  young  cells  gradually  collect  at  the  points 
where  the  connective-tissue  corpuscles  lay,  while  intermediate  sub- 
stance constantly  decreases,  and  how  in  the  middle  of  the  drawing,  in 
the  centre  of  the  inflamed  spot,  the  groups  of  cells  unite  and  form  a 
collection  of  pus ;  every  abscess  at  first  consists  of  such  separate  col- 
lections of  pus ;  it  grows  by  pei'ipheral  extension  of  the  suppuration. 
Formerly,  it  was  not  doubted  that,  wherever  pus-cells  thus  appeared 

F16.  64. 


Diagram  of  pnmlent  infiltration  of  the  cutis  connective  tissue,  fonnlng  an  abscess  in  the 
middle.    Magnified  3S0  diameters. 


in  groups,  they  were  to  be  regarded  as  a  production  of  connective- 
tissue  cells ;  according  to  our  present  views,  there  is  no  doubt  that 
these  yoimg  cells  are  escaped  white  blood-cells,  and  are  simply  grouped 


316 


PHLEGMONOUS   INFLAMMATION. 


together  from  mrclianical  causes.     Tlie  fat,  which  is  usually  plentiful 
in  the  subcutaneous  cellular  tissue,  is  generally  destroyed  in  acute 


Fib,  65. 


Purulent  infiltra'iou  of  the  cellular  membrane.    Magnified  350  diamotere  ;  from  a  preparation 

hardened  In  alcohol. 

inflammation,  the  fat-cells  being  compressed  by  the  new  cell-masses, 
and  the  fat  becoming  fluid  ;  subsequently,  it  is  occasionally  found  in 
the  shape  of  oil-drops  mixed  with  the  pus.  In  this  preparation  you 
may  see  the  microscopic  appearance  in  inflammation  of  the  cellular 
membrane. 

In  examining  such  preparations  we  not  unfrequently  find  filaments 
of  coagulated  fibrine  infiltrated  in  the  tissue  ;  possibly  it  is  formed  at 
the  commencement  of  the  inflammation,  as  previously  described ;  but 
it  is  also  possible  that  these  filaments  appertain  only  to  the  fully- 
formed  pus — possibly  they  are  produced  by  the  alcohol. 

I  must  call  your  attention  to  the  fact  that,  until  the  process  is 
arrested,  we  always  have  a  progressive  softening  of  the  tissue,  or  sup 
puration,  in  which  it  differs  from  a  developed  granulating  surface, 
which  only  forms  pus  on  its  surface.  All  suppurative  parenchymatous 
inflammations  have  a  destructive  or  deleterious  action  on  the  tissue. 

As  regards  the  relation  of  the  blood-vessels  to  the  new  formation 
of  the  young  tissue  and  its  speedy  disintegration,  it  has  already  been 
stated  that  they  are  at  first  dilated,  and  then  the  blood  stagnates  in 
them ;  if  the  circulation  be  entirely  arrested  in  certain  portions  of 
tissue,  in  which  case  the  coagulation  in  the  veins  occasionally  extends 
a  considerable  distance,  the  Avails  of  the  vessels  and  the  clot  suppu- 
rate, or  fall  into  shreds,  as  far  as  the  border  where  the  circulation 


ACUTE  XON-TRAUMATIC  INl'LAMMATIOX  OF  SOFT  PARTS.      317 
Fio.  66. 


Vessels  (artificially  injected)  of  the  walls  of  an  abscess  that  had  been  induced  in  the  tongue  of 
a  dog.    Magnified  35  diameters. 

begins  again.  As  we  have  already  seen  when  studying  the  detach- 
ment of  necrosed  shreds  of  tissue,  vascular  loops  must  form  on  this 
border  of  the  living  tissue ;  that  is,  the  whole  inner  surface  of  an 
abscess,  in  the  arrangements  of  its  vessels,  is  analogous  to  a  granula- 
ting- surface  folded  up  sac-like. 

In  regard  to  the  lymphatic  vessels,  we  may  conclude  from  analogy 
that  here,  as  in  the  vicinity  of  wounds,  they  are  closed  by  the  inflam- 
matory neoplasia;  special  investigations  on  this  subject  would  be 
very  desirable.  So  soon  and  so  long  as  an  abscess  is  surrounded  by 
a  vigorous  layer  of  tissue  infiltrated  with  plastic  matter,  for  reasons 
already  mentioned  there  will  be  no  reabsorption  of  purulent  or  putrid 
substances  from  the  cavity  of  the  abscess.  I  can  give  you  practical 
e"vddence  of  this,  if  in  the  clinic  you  will  smell  pus  from  an  abscess 
near  the  rectum  or  in  the  mouth  ;  this  pus  has  an  exceedingly  pene- 
trating, putrid  odor,  still  is  not  reabsorbed  by  the  walls  of  the  veins, 
or  is  so  to  only  a  very  slight  extent ;  symptoms  of  general  sepsis  verj 
rarely  occur.  But  at  the  commencement  of  inflammation,  and  later, 
Avhen  it  is  accompanied  by  rapid  destruction  of  tissue,  as  well  as  in 
some  progressive  inflammations  around  contused  wounds,  and  in 
phlegmonous  inflammation  of  the  cellular  tissue,  etc.,  if  the  h'mphalic 
i^essels  are  not  yet  stopped  by  cell-formation,  organized  inflammatory 
new  formation  does  not  occur,  or  comes  on  late  as  the  gangrenoua 


318  PHLEGMONOUS  INFLAMMATION. 

destruction  is  being  bounded;  then  the  decomposing  tissue  enters 
the  open  lymphatics  and  acts  as  a  ferment  in  the  blood,  causing  fever. 

Although  inflammation  of  the  cellular  tissue  (cellulitis)  may  occur 
at  any  part  of  the  body,  it  is  most  frequent  in  the  hand,  forearm,  knee, 
foot,  and  leg.  It  is  often  accompanied,  and,  when  extending,  preceded, 
by  lymphangitis,  of  which  we  shall  speak  among  the  accidental  trau- 
matic diseases. 

The  intensity  and  duration  of  the  fever,  accompanying  these  in- 
flammations, depend  on  the  quantity  and  quality  of  the  material  re- 
absorbed. At  first  a  quantity  of  these  matters  is  thrown  into  the 
blood  at  once,  hence  at  the  onset  there  is  usually  high  fever,  some- 
times chill;  as  the  inflammation  progresses,  the  fever  continues;  it 
ceases  when  further  absorption  of  the  inflammatory  product  is  arrest- 
ed by  the  above  changes  of  tissue,  when  the  process  stops  and  the 
abscess  is  formed.  The  quality  of  the  inflammatory  material  formed 
in  cellular  inflammation  certainly  varies  greatly ;  for  instance,  in  some 
cases  deep  in  the  neck  in  old  people  there  is  such  intense  poisoning 
that  the  patients  die  without  other  symptoms.  It  is  here  the  same 
as  in  carbuncle — some  cases  cause  little  fever,  others  produce  fatal 
septic  fever.  If  a  phlegmon  be  due  to  a  dangerous  poison,  such  as  that 
of  glanders,  we  do  not  wonder  at  the  fatal  termination;  but  for  the 
spontaneous  cases  it  often  seems  very  strange  why  some  should  be  so 
very  severe,  while  most  of  them  are  relatively  mild. 

The  prognosis  of  phlegmonous  inflammations  varies  immensely 
with  the  location,  extent,  and  cause.  While  the  disease,  occurring  as 
a  metastasis  in  a  general  phlogistic  or  suppurative  diathesis,  or  in 
glanders,  gives  little  hopes  of  cure,  while  deeply-seated  abscesses  in 
the  walls  of  the  abdomen  or  in  the  pelvis  are  very  slow  in  their  course 
and  may  prove  dangerous  from  the  locality,  or,  by  destruction  of  fas- 
ciae, tendons,  and  skin,  may  impair  the  functions,  most  cases  of  phleg- 
mon on  the  fingers,  hand,  forearm,  etc.,  are  only  moderate  diseases  of 
short  duration,  although  very  painful.  The  sooner  suppuration  occurs 
and  the  more  circumscribed  the  inflammation,  the  better  the  prognosis 

As  regards  the  treatment,  at  the  commencement  of  the  disease  its 
aim  is  to  arrest  the  development  of  the  disease  if  possible,  that  is,  to 
attain  the  earliest  possible  reabsorption  of  the  serous  and  plastic  in- 
filtration. For  this  purpose  there  are  various  remedies :  first,  the  ex- 
ternal use  of  mercury ;  the  inflamed  part  may  be  smeared  with  mer- 
curial ointment,  the  patient  placed  in  bed,  and  the  inflamed  extremity 
enveloped  in  warm,  moist  cloths  or  large  cataplasms.  Ice  also  may 
be  employed  at  first,  if  the  whole  inflamed  part  can  be  covered  with 
several  bladders  of  ice.  Compression  by  adhesive  plaster  and  band- 
ages is  also  a  very  effective  remedy  for  aiding  absorption,  but  it  is 


ACUTE  XON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.      319 

little  used  in  these  inflammations,  partly  because  of  the  pain  it  causes 
in  such  cases,  partly  because  the  remedy  is  not  free  from  danger,  as 
gangrene  may  be  easily  induced  by  a  little  too  much  pressure.  If  the 
process  be  not  moderated  soon  after  the  employment  of  the  above 
remedies,  but  all  the  symptoms  increase,  we  must  give  up  the  hope  ot 
resolution,  and  resort  to  remedies  to  hasten  the  suppuration  which  we 
cannot  avert ;  the  chief  of  these  is  the  application  of  moist  warmth, 
especially  in  the  shape  of  cataplasms.  Then,  as  soon  as  fluctuation  is 
detected  at  any  point,  we  do  not  usually  leave  the  perforation  to  Na- 
ture, but  di\dde  the  skin  to  give  vent  to  the  matter;  if  the  suppuration 
extends  under  the  skin,  we  make  several  openings,  at  least  I  prefer 
this  to  one  very  large  incision,  from  the  elbow  to  the  hand  for  instance, 
because  in  the  latter  the  skin  gapes  widely,  and  takes  a  long  time  to 
heal.  If  the  pus  escapes  naturally  from  the  openings,  great  cleanHness 
is  the  only  thing  necessary ;  this  is  greatly  assisted  by  local  warm 
baths. 

"W^iile  it  is  a  very  simple  thing  to  open  subcutaneous  abscesses, 
"  oncotomy  "  of  deep  abscesses  requires  great  attention  to  the  anato- 
my of  the  locahty :  for  instance,  the  diagnosis  may  be  very  difficult  in 
suppurations  deep  in  the  neck,  in  the  pelvis,  in  the  abdominal  wall, 
etc.,  and  can  only  be  certainly  made  after  a  long  period  of  observation; 
still,  partly  for  the  relief  of  the  patient,  partly  to  avoid  a  spontaneous 
opening  into  the  abdomen,  perhaps  it  may  be  desirable  to  evacuate 
the  pus  early.  In  such  cases  we  must  not  plunge  a  bistoury  boldly 
in,  but  dissect  up  laj'er  after  layer,  till  we  reach  the  fluctuating  cover- 
ing of  the  abscess ;  then  introduce  a  probe  carefully,  and  dilate  the 
opening  by  extending  the  blades  of  forceps  introduced  into  it,  so  as  to 
avoid  haemorrhage  from  the  deeper  parts.  Occasionally  decompo- 
sition of  the  pus  in  an  abscess  causes  so  much  gas  as  to  give  rise 
to  a  tjTnpanitic  percussion-sound;  after  being  opened,  these  putrid 
abscesses  should  be  syringed  out  and  dressed  with  chlorine- water. 

4.  ACUTE  INFLAMMATION  OF  THE  MUSCLES. 

Idiopathic  acute  inflammation  of  muscular  substance  is  rela- 
tively rare.  It  occin-s  in  the  muscles  of  the  tongue,  in  the  psoas, 
pectoral,  and  gluteal  muscles,  and  in  those  of  the  thigh  and  calf 
of  the  leg;  the  usual  termination  is  in  abscess,  although  resolution 
has  been  observed.  Metastatic  muscular  abscesses  are  very  frequent 
in  glanders.  Regarding  the  special  histological  conditions,  the  in- 
terstitial connective  tissue  of  the  muscles,  the  perimysium  is  here, 
as  in  traumatic  myositis,  the  chief  seat  of  the  purulent  infiltration; 
from   the   very  acute  disease,  the  nuclei  of  the  muscular  filaments 


320      INFLAMMATIOX  OF  THE  SHEATHS  OF  TENDONS. 

are  destroyed,  with  the  contractile  substance  and  the  sarcolemma; 
only  on  the  stumps  of  the  muscular  filaments  in  the  caj^sule  of 
the  abscess  do  we  find  the  muscular  nuclei  (muscular  corpuscles) 
in  groups  and  adherent  to  the  cicatrix ;  in  such  cases,  according  to  0. 
Weber,  there  is  a  considerable  new  formation  of  young  muscle-cells. 
The  symptoms  of  an  abscess  in  the  muscle  are  the  same  as  those  of 
any  deep  abscess ;  their  periods  of  development  and  perforation  vary 
with  their  size  and  extent.  In  many  cases  there  is  contraction  of  the 
muscles  in  whose  substance  the  abscess  develops,  as  in  psoitis.  I  shall 
not  discuss  whether  this  is  the  physiological  result  of  the  inflammatory 
irritation,  or  whether  it  is  half  voluntarj',  and  made  instinctively  by 
the  patient,  but  am  rather  inclined  to  the  latter  view,  for  in  small 
and  not  very  painful  abscesses  and  in  traumatic  inflammations  of  the 
muscles,  there  is  usually  no  contraction,  but  this  occurs  only  in  large  al> 
scesses,  which  are  compressed  by  strong  fascise.  Abscesses  in  muscles 
should  be  opened  as  soon  as  fluctuation  is  felt,  and  the  diagnosis 
certain. 

A  very  peculiar  form  of  disease  of  the  muscles,  which,  according  to 
my  view,  should  be  classed  among  subcutaneous  inflammations,  has 
been  recently  discovered  and  described  by  Zenker ,'  it  occurs  chiefly  in 
typhoid  fever,  in  the  adductor  muscles  of  the  thigh ;  in  it  the  contrac- 
tile substance  in  the  sarcolemma  crumbles  and  is  gradually  absorbed, 
while  new  muscular  filaments  form  to  replace  the  old.  Thus,  in  most 
cases,  the  parts  are  fully  restored  ;  in  other  cases  permanent  atrophy 
of  the  muscle  remains.  There  is  no  accurate  knowledge  as  to  whether 
this  disease  may  lead  to  suppuration,  although  abscesses  of  the  ab- 
dominal muscles  have  been  observed  after  typhus. 

6.  ACUTE  INFLAMMATION  OF  THE  SHEATHS  OF  TENDONS  AND  SUB- 
CUTANEOUS  MUCOUS  BUES^  (SEEOUS  MEMBKANES). 

As  is  well  known,  the  sheaths  of  tendons  form  shut  sacs,  which 
enclose  some  of  the  tendons  of  the  hands  and  feet.  They  may  be- 
come acutely  inflamed  from  contusion,  and  in  some  few  cases  also 
spontaneously.  Like  all  acutely-inflamed  serous  membranes,  these 
sacs  at  first  exude  a  quantity  of  fibrinous  senmi ;  recent  fibrinous 
pseudo-membranes  composed  of  wandering  cells  may  again  dissolve, 
but  they  may  also  induce  temporary  or  permanent  adhesions  of  the 
sheath  to  the  tendon ;  lastly,  there  is  not  unfrequently  suppura- 
tion of  the  membrane,  and  at  this  time  the  tendon  may  become 
necrosed.  Pain  on  motion  and  slight  swelling  are  the  first  signs 
of  such  inflammation ;  occasionally  there  is  friction-sound,  a  grating 
in  the  sheath  of  the  tendon,  which  may  be  perceived  by  the  hand, 
or,  still  better,  by  the  ear.  This  noise  is  due  to  the  surfaces  of 
the  tendon  and  of  its  sheath  ha^^ng  become  rough  from  deposits  of 


ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.       321 

fibrine  and  rubbing  against  each  otlier,  wben  the  tendons  are  moved ; 
this  form  of  subcutaneous  inflammation  is  most  common  on  the  back 
of  the  hand,  and  ahnost  always  terminates  in  resohition.  The  very 
acute  inflammations  of  the  sheaths  of  the  tendons,  arising  from  un- 
known causes  and  going  on  to  suppuration,  are  rare  ;  they  begin  like 
an  acute  phlegmon ;  the  subcutaneous  cellular  tissue  quickly  partici- 
pates in  the  inflammation ;  the  limb  swells  greatly,  and  the  adjacent 
finger  or  wrist-joint  may  be  drawn  into  the  inflammation.  Like  the 
S}Tiovial  membrane  of  the  joints,  that  of  the  tendinous  sheaths  occa- 
sionally seems  to  furnish  products  that  intensely  afl'ect  the  surround- 
ing parts.  If,  under  suitable  treatment,  the  disease  does  not  go  on  to 
suppuration,  or,  if  this  be  only  partial,  resolution  slowly  occurs ;  the 
liml:)  remains  stiff  a  long  while;  the  adhesions  between  the  tendon 
and  its  sheath  do  not  break  down  till  after  months  of  use.  If  there  be 
extensive  suppuration  of  the  sheaths  of  the  tendon  (which,  in  the  hand, 
has  been  termed  "panaritium  tendinosum"),  the  tendons  usually  be- 
come necrosed,  and  after  a  time  may  be  drawn  out  of  the  abscess 
openings  as  white  threads  and  shreds ;  the  membrane  then  degener- 
ates to  spongy  granulations.  If  the  process  be  now  arrested,  one  or 
more  fingers  will  be  stifle,  and  remain  so  for  life.  If  the  joints  be  also 
attacked  in  the  fingers,  there  may  be  recovery  with  anchylosis ;  but,  if 
the  wrist  or  ankle-joint  be  affected,  its  existence  will  be  greatly  endan- 
gered. In  acute  suppurative  inflammation  of  the  tendinous  sheaths, 
the  fever  is  occasionally  slight  at  first,  but  in  severe  cases  the  disease 
may  begin  with  a  chill.  The  further  the  inflammation  and  suppuration 
extend,  the  less  the  process  tends  to  formation  of  an  abscess,  the  more 
continued  tlie  fever  becomes,  and  it  assumes  a  distinctly  remittent 
form  ;  at  the  same  time  the  patients  are  rapidly  pulled  down ;  in  a  few 
weeks  the  strongest  men  emaciate  to  skeletons.  The  prognosis  is 
bad  when  the  fever  runs  on  with  intermittent  attacks  and  chills. 

The  treatment  of  subcutaneous,  crepitating  inflammations  of  the 
sheaths  of  the  tendons  consists  in  keeping  the  part  quiet  on  a  splint, 
and  painting  it  with  tincture  of  iodine ;  if  this  does  not  afford  speedy- 
relief,  a  blister  may  be  applied ;  under  this  treatment  I  have  always 
seen  this  form  of  inflammation  disappear  in  a  few  days.  If  the  symp- 
toms are  severe  from  the  first,  quiet  of  the  part  is  the  first  requisite ; 
this  should  be  seconded  by  mercurial  ointment  and  bladders  of  ice. 
This  treatment  should  be  persistently  pursued ;  in  these  cases  I  de- 
cidedly prefer  it  to  cataplasms  and  local  warm  baths,  which  are  very 
common.  If  absceses  form,  incisions  and  plenty  of  counter-openings 
should  be  made  ;  in  these  cases  drainage-tubes  are  very  useful,  because 
the  granulations  projecting  from  the  openings  often  obstruct  the 
escape  of  the  pus.  If  the  suppuration  Avill  not  stop,  if  the  spongy 
22 


322         INFLAMMATIONS   OF  SUBCUTANEOUS   MUCOUS  BUES.E. 

swelling  of  the  limb  continues,  if  crepitation  appears  in  the  joint  be« 
tween  the  bones  of  the  wrist  (showing  that  the  cartilaginous  coverings 
have  suppurated),  and  if  the  patient  continues  to  sink,  there  is  little 
hope  of  a  termination  in  anchylosis  of  the  hand,  but  the  danger  to 
life  is  so  great  that  amputation  of  the  forearm  should  be  made ;  the 
patient  may  thus  escape  with  his  life,  and  will  soon  recover  his 
strength. 

Acute  inflammations  of  the  subcutaneous  miicoKS  bursce  are  less 
dangerous ;  the  bursa  praepatellaris  and  anconea  are  most  frequently 
affected  either  from  injury  or  spontaneously ;  they  are  connected 
neither  with  the  joint  nor  with  the  sheaths  of  the  tendons  ;  they  be- 
come painful,  fill  with  fibrinous  serum,  the  skin  reddens,  and  the  cel- 
lular tissue  in  the  vicinity  participates  in  the  inflammation ;  but  sup- 
puration rarely  occurs  if  the  patient  is  treated  early.  The  remedies 
are  mercurial  ointment  or  tincture  of  iodine,  keeping  tlie  limb  quiet, 
and  compressing  the  swollen  bursa  by  applying  wet  bandages. 
Puncture  is  unnecessary,  and  may  be  injurious,  from  being  followed  by 
suppuration  and  a  tedious  suppurating  fistula. 

Limitation  of  carbuncle  to  the  skin  and  subcutaneous  cellular 
tissue  is  very  characteristic  of  fibrinous  (diphtheritic)  inflamma- 
tions ;  so  that  on  this  account,  as  well  as  from  the  hard  infiltration 
and  necrosis  of  the  tissue  once  infiltrated,  I  do  not  hesitate  to  con- 
sider carbuncle  as  a  diphtheritic  inflammation  of  the  skin.  I  have 
had  no  opportunity  of  examining  to  see  if  there  are  micrococci  in 
the  freshly-expressed  juice  of  carbuncle  ;  finding  a  few  of  them  in 
the  exposed  shreds  of  necrosed  tissue  would  prove  nothing  about 
the  origin  of  the  carbuncle.  [In  diphtheria  of  mucous  membranes, 
as  well  as  in  that  of  wounds,  the  infiltrated  tissue  contains  micrococci 
constantly  multiplying.  It  was  long  disputed  whether  these  were 
merely  accidental  accompaniments  or  the  actual  exciters  of  the  dis- 
ease. IN'ow  it  seems  proved  that  by  cultivation  in  proper  fluids  they 
may  be  separated  from  the  organic  decomposing  products  clinging  to 
tbem  ;  that  after  inoculation  in  living  tissue  there  is  active  increase  ; 
that  the  fungi  enter  the  tissue,  and  by  their  mechanical  and  perhaps 
chemical  irritation  induce  a  peculiar  inflammation,  characterized  by 
the  coagulating  transudation  permeating  the  tissues.  Chemical 
products  of  very  poisonous  character  form,  cling  to  the  micrococci, 
and  are  carried  along  witb  them.  The  more  rapidly  these  sub- 
stances are  absorbed,  the  larger  the  amount  absorbed,  the  more  in- 
tense the  constitutional  effect.]  Kochmann  thinks  that  carbuncle  as 
well  as  furuncle  originally  develops  from  a  sweat-gland,  or  from 
several  adjacent  glands.  J.  Keuimann  distinguishes  between  car- 
buncles from  sweat-glands  and  from  cellular  tissue.     I  cannot  say 


ACUTE  NON-TRAUMATIC  INFLAMMATION  OF  SOFT  PARTS.       323 

whether  there  is  any  justice  in  this  distinction,  as  I  too  rarely  see 
carbuncle  in  its  first  stages. 

The  inflammation  described  (p,  308)  cannot  be  considered  ex- 
actly as  carbuncle  ;  it  is  rather  a  carbunculous  inflammation  of  the 
skin  and  subcutaneous  tissue,  which  I  should  now  prefer  to  call 
diphtheritic  phlegmon  ;  the  accompanying  erysipelatous  redness 
also  corresponds  with  diphtheritis. 

The  great  difference  of  the  constitutional  symptoms  in  carbuncles 
agrees  very  well  with  the  supposition  that  they  are  of  diphtheritic 
nature,  where  it  is  characteristic  for  the  local  extent  not  to  corre- 
spond to  the  general  toxic  symptoms.  I  do  not  know  if  paralyses 
ever  occur  after  carbuncle,  as  they  do  after  pharyngeal  and  laryn- 
geal diphtheria. 

You  will  often  hear  that  early  incisions  in  phlegmonous  inflam- 
mation will  prevent  the  skin  from  becoming  gangrenous  or  suppu- 
rating. Unfortunately,  I  cannot  confirm  this.  I  have  found  it  to  * 
depend  more  on  the  intensity  of  the  inflammation  than  on  the  ten- 
sion of  the  skin.  Still,  I  consider  early  incisions  proper  in  phleg- 
monous inflammation,  as  it  seems  that  by  carefully  pressing  the 
serum  out  of  the  inflamed  tissue  we  may  sometim.es  arrest  the  prog- 
ress of  the  affection. 


CHAPTER  XI. 

iCUTE  INFLAMMATIONS,    OF  THE  BONES,  PERT 
0STEU3L  AND  JOINTS. 


LECTURE    XXII. 

Anatomy. — Acute  Periostitis  and  Osteomyelitis  of  the  Lonff  Bones :  Symptoms,  Ter- 
minations in  Eesolution,  Suppuration,  Necrosis,  Prognosis,  Treatment. — Acute 
Ostitis  in  Sponj^y  Bones. — Acute  Inflammations  of  tlie  Joint.s. — Hydrops  Acutus  ; 
Symptoms,  Treatment. — Acute  Suppurative  Inflammations  of  Joints:  Symptoms, 
Course,  Treatment,  Anatomy. — Acute  Articular  IJheumatism. — Artliritis. — Metas- 
tatic Inflammations  of  Joints  (Gonorrhceal,  Pyemic,  Puerperal). 

The  periosteum  and  the  bones  are  pliysiologically  so  intimately 
connected  that  disease  of  one  generally  affects  the  other ;  although, 
in  spite  of  this,  we  are,  for  practical  reasons,  obliged  to  consider  acute 
and  chronic  inflammation  of  the  periosteum  and  of  bone  separately, 
still  we  shall  often  have  to  refer  to  their  connection.  I  must  here  make 
a  few  preliminary  anatomical  remarks,  as  they  are  important  for  the 
comprehension  of  the  following  process  :  When  speaking  briefly  of 
the  periosteum,  we  usually  mean,  simply,  the  white,  glistening,  thin 
membrane,  poor  in  vessels,  which  immediately  surrounds  the  bone.  I 
must  here  remark  that  this  represents  only  a  part  of  the  periosteum 
that  is  pathologically  of  little  relative  importance.  Upon  this  just 
described  inner  layer  of  the  periosteum  lies,  at  points  where  no  ten 
dons  or  ligaments  are  inserted,  a  layer  of  loose  cellular  tissue,  which 
is  also  to  be  considered  as  periosteum,  and  in  which  principally  lie  the 
vessels  that  enter  the  bone.  This  outer  laj^er  of  periosteum  is  the 
most  frequent  seat  of  primary  inflammations,  either  acute  or  chronic ; 
the  loose  cellular  tissue  of  which  this  layer  consists  is  very  rich  in 
cells  and  vessels,  hence  more  inclined  to  inflammation  than  is  the  ten- 
dinous portion,  poor  in  cells  and  vessels,  which  lies  immediately  on 
the  bone.  As  to  nutrient  vessels,  especially  iu  the  long  bones,  the 
epiphyses  have  their  own  supply,  which,  as  lone-  as  the  epiphyseal  car^ 


ACUTE   PERIOSTITIS.  325 

tilages  continue,  do  not  communicate  with  the  vessels  of  the  diaphysis, 
which  have  tlieir  own  nutrient  arteries.  This  distribution  of  the  ves- 
sels explains  why  diseases  of  the  diaphyses  in  yovmg  persons  rarely 
pass  to  the  epiphj-scs  and  the  reverse.  Genetically  the  articular  cap- 
sule is  a  continuation  of  the  periosteum,  and  a  certain  connection  is 
often  observed  between  articular  and  periosteal  diseases,  the  diseases 
of  one  readily  passing  to  the  other.  In  the  course  of  the  following 
observations  we  shall  have  occasion  to  recur  to  these  anatomical  con- 
ditions. 

First,  let  us  speak  of  acute  periostitis  and  osteomyelitis^  of  which 
you  have  already  heard  something  in  the  remarks  on  suppuration 
of  bone  in  the  chapter  on  open  fractures  (p.  211).  This  disease 
is  not  very  frequent ;  it  occm-s  chiefly  in  young  persons,  and  in  its 
typical  forms  almost  exclusively  in  the  long  bones.  The  femur  is 
most  frequently  attacked,  next  the  tibia,  more  rarely  the  humerus  and 
bones  of  the  forearm.  I  have  seen  the  disease  occur  primarily  or 
secondarily  in  the  vicinity  of  acutely-inflamed  joints,  after  catching 
cold,  and  after  severe  concussions  and  contusions  of  the  bones.  It  is 
possible  that  the  extravasation  into  the  medulla  from  crushing  or  con- 
tusion of  a  bone  may  be  reabsorbed,  without  the  occurrence  of  any 
symptom  but  a  continued  pain  as  the  result  of  the  injury ;  but  such 
injuries  may  occasionally  induce  chronic  affections  of  various  sorts. 

In  many  cases  we  cannot  discover  whether  only  the  periosteum  or 
the  medulla  of  the  bone  is  affected ;  the  distinction  is  usually  only  ren- 
dered certain  by  the  subsequent  course  and  by  the  termination.  The 
symptoms  are  as  follows  :  The  disease  begins  with  high  fever,  not  uu- 
frequently  with  a  chill ;  ther*^  ]«  severe  pain  in  the  affected  limb,  which 
owells  at  first  without  redness.  The  severe  pain  prevents  motion  of 
the  limb;  every  touch  or  the  slightest  jarring  is  very  painful;  the 
skin  is  tense,  usually  oedematous,  and  occasionally  the  distended  sub- 
cutaneous veins  show  through,  a  sign  that  the  flow  of  blood  to  the 
deeper  parts  is  obstructed.  The  inflammation  may  affect  the  whole 
or  only  jDart  of  a  bone.  But  these  symptoms  simply  indicate  the  ex- 
istence of  an  intense  deeply-seated  acute  inflammation.  But  as  idio- 
pathic inflammation  of  the  perimuscular  and  peritendinous  cellular 
tissue  is  very  unfrequent,  and  rarely  begins  with  so  much  pain,  we 
shall  not  err  in  most  cases  if,  with  the  above  symptoms,  we  diagnosti- 
cate acute  periostitis,  perhaps  accompanied  by  osteomyelitis.  If,  while 
there  are  great  \)am.  and  fever,  or  complete  inability  to  move  the  limb 
on  account  of  pain,  swelling  does  not  occur  for  several  days,  Ave  may 
suspect  that  the  primary  seat  of  the  inflammation  is  the  medulLiry 
cavity  of  the  bone,  and  that  at  first  the  periosteum  participates  but 
little.     In  this  stage  the  diseased  part  is  in  about  the  following  con- 


326      ACUTE  INFLAMMATIONS  OF  THE  BONES,  PERIOSTEUM,  ETC. 

dition :  The  vessels  of  the  medulla  and  periosteum  are  greatly  dilated 
and  distended  with  blood ;  perhaps  there  may  be  stasis  of  blood  at 
different  points.  The  medulla,  instead  of  its  usual  bright-yellow 
color,  is  dark  blue,  and  permeated  with  extravasations ;  the  perios- 
teum is  greatly  infiltrated,  and  on  microscopical  examination  of  it  you 
find  numbers  of  young  cells,  as  you  also  do  in  the  medulla ;  that  is, 
there  is  plastic  infiltration.  In  this  stage,  a  complete  return  to  the 
normal  state  is  possible,  and,  if  proper  treatment  is  begun  earlj^,  this 
is  not  so  rare,  particularly  in  the  more  subacute  cases.  The  fever 
falls,  the  swelling  decreases,  and  the  pain  ceases ;  a  fortnight  after  the 
commencement  of  the  disease  the  patient  may  be  recovered.  Even 
when  the  process  is  somewhat  further  advanced,  it  may  stop ;  then  a 
part  of  the  new  formation  on  the  surface  of  the  bone  ossifies,  and  thus, 
for  a  time  at  least,  there  is  thickening  of  the  afi'ected  bone,  which  may 
affain  be  absorbed  in  the  course  of  months. 

o 

In  most  cases  the  course  of  periostitis  is  not  so  favorable,  but  the 
process  goes  on,  and  terminates  in  suppuration,  the  symptoms  being 
as  follows :  The  skin  of  tlie  swollen,  tense,  and  painful  limb  is  at  first 
reddish,  then  brownish  red  ;  the  oedema  extends  further  and  further; 
the  neighboring  joints  become  painful,  and  swell ;  the  fever  remains 
at  the  same  point;  the  chills  are  not  infrequently  rejDeated.  The 
patient  is  much  exhausted,  as  he  eats  little,  and  at  night  is  kept 
awake  by  the  pain.  Toward  the  twelfth  or  fom-teenth  day  of  tlie  dis- 
ease, rarely  earlier,  but  often  later,  we  may  clearly  distinguish  fluctu- 
ation, and  may  then  greatly  alleviate  the  sufferings  of  the  patient  by 
letting  out  the  pus  through  one  or  more  openings,  if  the  skin  over  the 
abscess  is  sufficiently  thinned;  for  the  opening  of  deep,  stitf- walled 
abscesses  w^hich  do  not  collapse  may  prove  dangerous  from  decompo- 
sition of  blood  and  pus  in  the  insufficiently-encapsulated  abscess. 
The  spontaneous  perforation,  especially  the  suppuration  of  the  fascias, 
occasionally  takes  a  good  while,  and,  moreover,  the  openings  thus 
formed  are  usually  too  small ;  they  must  subsequently  be  enlarged. 
If  you  introduce  the  finger  through  one  of  these  artificial  openings, 
you  come  directly  on  the  bone,  and  in  many  cases  find  it  denuded  of 
periosteum.  The  extent  to  which  this  denudation  occurs  depends  on 
the  extent  of  the  periostitis.  It  may  extend  the  whole  length  of  the 
diaphysis,  and  in  these  worst  cases  the  S}Tnptoms  are  the  most  severe. 
Probably,  however,  only  a  half  or  a  third  of  the  periosteum  is  dis- 
eased, nor  is  the  entire  circumference  of  the  bone  necessarily  aflFected, 
but  perhaps  only  the  anterior,  lateral,  or  posterior  portion  is  so.  The 
periostitis  is  particularly  apt  to  stop  at  the  points  of  origin  or  inser- 
tion of  strong  muscles.  In  those  cases  of  slight  extent  all  the  symp 
toms  will  be  milder. 


ACUTE   PERIOSTITIS.  327 

Even  in  this  stage  the  disease  may  take  one  of  two  different  direc- 
tions:  possibly,  after  the  evacuation  of  the  pus,  the  soft  parts  ?aay 
quickly  become  adherent  to  the  bone,  as  the  walls  of  an  acute  abscess 
do  to  each  other.  I  have  seen  this  a  few  times  in  periostitis  of  the 
femur  in  children  two  or  three  years  old.  After  the  opening,  a  slight 
quantity  of  pus  continued  to  discharge  for  only  a  short  time.  The 
openings  soon  closed  entirel}^,  the  tumor  receded,  and  perfect  recovery 
took  place.  But,  according  to  my  experience,  such  a  termination  only 
occurs  in  small  children.  More  frequently,  as  a  result  of  the  suppu- 
ration of  the  periosteum,  the  bone  is  mostly  robbed  of  its  nutriunt 
vessels,  and  partly  or  Avholly  dies,  leaving  the  condition  ternied 
necrosis,  or  gangrene  of  the  bone.  The  extent  of  this  necrosis  v  ill 
essentially  depend  on  the  extent  of  the  periostitis.  The  partially  or 
entirely  destro3'ed  diaphysis  of  the  long  bones  must  be  detached  as  a 
foreign  body,  as  we  have  seen  to  be  the  case  in  gangrene  of  the  soft 
parts  and  traumatic  necrosis.  This  requires  a  long  time  ;  hence  the 
process  of  necrosis,  the  detachment  of  the  portion  of  dead  bone  or 
sequestrum,  and  every  thing  connected  with  it,  is  always  a  chronic 
one.  We  shall  have  to  speak  of  this  hereafter.  Before  the  inflamma- 
tion passes  into  this  chronic  state,  acute  suppuration  continues  for  a 
time  after  the  first  opening  of  the  abscess.  Various  complications, 
even  p3'femia,  may  occur.  Whenever  these  patients  are  feverish,  they 
are  in  danger. 

AVe  must  again  return  to  the  medulla  of  the  bone,  which  we  left 
in  the  first  stage  of  inflammation.  Here,  also,  the  inflammation  may 
terminate  in  suppuration.  If  the  osteomyelitis  be  diffuse  or  total,  the 
whole  medulla  may  suppurate.  This  suppuration  may  even  assume  a 
putrid  character,  and  induce  septicsemia.  If  there  be  extensive  sup- 
purative osteomyelitis,  Avith  suppurative  periostitis,  death  of  the  dia- 
physis of  the  bone  is  certain.  Should  there  be  only  partial  suppura- 
tion of  the  medulla,  or  if  there  be  none  at  all,  the  circulation  of  blood 
in  the  bone  may  be  presented  and  the  bone  remain  viable.  It  may 
not  infrequently  occur  that,  under  such  circvmistances,  the  bone  will 
waver  for  a  time  between  life  and  death,  as  the  feeble  circulation 
nourishes  the  bone  very  incompletely.  Acute  suppurative  osteomye- 
litis, without  participation  of  the  periosteum, probably  does  not  occur; 
it  is  not  infrequently  combined  with  osteophlebitis,  which  may  end  in 
putrefaction  or  suppuration  of  the  thrombus,  and  is  prone  to  induce 
metastatic  abscesses.  Another  not  infrequent,  though  not  constant, 
accompaniment  of  osteomyelitis  is  suppuration  of  the  epiphyseal  car- 
tilages in  persons  in  whom  they  still  exist,  that  is,  till  about  the 
twenty-fourth  year.  The  process  is  not  diflicult  to  explain.  The  sup- 
puration may  extend  to  the   epiphyseal   cartilage  partly  from    tht 


328      ACUTE  INFLAMMATIONS  OF  THE  RONES,  PERIOSTEUM,  ETC. 

medulla  of  tlie  bone,  partly  from  the  periosteum.  If  it  suppurate, 
tlie  continuity  of  the  bone  is  destroyed,  and  at  the  seat  of  the  epi- 
physis there  is  motion,  as  in  fracture ;  dislocations  may  also  be  caused 
by  contraction  of  the  muscles.  Usually  there  is  only  one  such  epi- 
physeal separation  of  the  affected  bone,  above  or  below  ;  in  rare  cases 
it  is  double.  I  have  once  seen  this  double  separation  of  the  epiphy- 
ses in  the  tibia ;  several  times  I  have  seen  separation  of  the  lower 
epiphysis  of  the  femur,  once  of  the  upper  end  of  this  bone,  once  of 
the  lower  end  of  the  humei'us,  twice  of  the  upper  end.  In  one  case 
I  saw  epiphyseal  softening,  with  luxation  of  the  lower  end  of  the 
femur,  occur  without  suppuration.  It  has  already  been  stated  that 
inflammation  of  the  neighboring  joints  are  apt  to  accompany  perios- 
titis. These  articular  inflammations  usuall}'  have  a  rather  subacute 
course.  The  serous  fluid  collecting  in  the  joint  is  usually  reabsorbed 
as  the  acute  disease  of  the  bone  subsides,  but  the  joint  often  remains 
swollen,  and  not  infrequently  permanently  stiff.  Several  times,  also, 
I  have  seen  acute  periostitis  and  osteorayelitia  of  the  femur  succeed 
acute  articular  rheumatism  of  the  knee.  Lastly,  we  must  also  men- 
tion that  this  osteomyelitis  may  occur  in  several  bones  at  once. 

The  diagnosis  as  to  how  far  periosteum  and  bone  are  affected  in 
the  acute  disease  cannot  be  made  with  any  certainty,  but  can  only  be 
decided  by  the  extent  of  the  consequent  necrosis ;  and  even  this  is  no 
accurate  measure,  for  the  periostitis  may  end  in  suppuration,  while 
the  inflammation  in  the  bone  may  end  in  resolution,  or  only  cause 
some  interstitial  formation  of  bone.  The  process  may  start :  1.  In 
the  loose  cellular-tissue  layer  of  the  periosteum ;  this  suppurates. 
If  the  suppuration  be  limited  to  this  hiyer,  after  opening  the  abscess 
we  may  pass  the  finger  directly  to  the  surface  of  the  bone,  which  we 
find  covered  Avith  the  granulating  tendinous  part  of  the  periosteum  ; 
if  the  latter  layer  also  suppurates,  as  it  not  infrequently  does,  the 
bone  lies  exposed,  and  the  suppuration  may  continue  into  it.  Thus 
osteomyelitis  accompanies  periostitis.  If  it  be  denied  that  the  loose 
cellular  layer  is  periosteum,  but  is  to  be  regarded  as  part  of  the  inter- 
muscular cellular  tissue  (which  would  not  be  natural,  because  the 
vessels  escaping  fi-om  the  bone  lie  chiefly  in  this  layer),  then  there  is 
no  such  thing  as  acute  periostitis  ;  for  the  tendinous  portion  of  the 
periosteum  is  as  little  liable  to  primary  inflammation  as  the  fascias  and 
tendons.  2.  The  inflammation  begins  in  the  bone,  and  thence  extends 
to  the  periosteum  and  cellular  tissue ;  osteom3''elitis  is  the  primary, 
periostitis  the  secondary,  disease.  Then  there  is  pus  not  only  in  the 
bone,  but  on  its  surface,  close  imder  the  tendinous  portion  of  the 
periosteum.  This  is  elevated  by  the  pus,  as  far  as  its  elasticity  per- 
mits ;  it  is  then  perforated,  and  the  pus  escapes  into  the  cellular  tissue 


ACUTE   PERIOSTITIS.  329 

Here  it  causes  more  suppuration,  and  thus  the  process  advances  to 
the  surface.  Hoser  asserts  that  in  these  cases  fluid  fat  is  pressed,  by 
the  strong  arterial  pressure,  from  the  cavity  of  the  bone  through  the 
Haversian  canals  of  the  cortical  substance  to  the  surface  of  the  bone, 
so  that  Ave  may  diagnose  osteomyelitis  from  pus  mixed  with  fat-drops 
rising  from  under  the  periosteum.  Moreover,  in  a  few  cases,  Hoser 
found  a  remarkable  elongation  of  the  bone,  and  a  relaxation  of  the 
neighboring  joints,  after  osteomyelitis.  He  refers  this  to  too  rajiid 
growth  of  the  articular  ligaments  and  epiphyseal  cartilages. 

In  the  prognosis  of  acute  periostitis  and  osteomyelitis  we  have  to 
distinguish  between  the  danger  to  the  existence  of  the  bone  and  to 
life.  If  the  disease  induces  partial  or  total  necrosis  of  the  bone,  the 
disease  may  be  very  protracted  ;  it  may  last  several  months,  or  even 
years.  Acute  periostitis  and  osteomyelitis,  especially  in  the  femur, 
and  still  more  when  double,  is  alwaj'^s  dangerous  to  life,  because  pyae- 
mia is  so  apt  to  occur,  and  in  children,  because  of  the  profuse  suppu- 
ration, it  is  the  more  dangerous  the  longer  the  condition  remains 
acute  and  the  further  it  spreads. 

In  treating  this  disease  we  may  accomplish  more  if  we  are  called 
eai'ly  ;  one  of  the  most  efficient  remedies  is  painting  the  whole  limb 
with  strong  tincture  of  iodine.  This  remedy  should  be  continued  tih 
large  vesicles  form.  Of  course  the  patient  is  to  be  kept  recumbent, 
which  in  most  cases  does  not  need  to  be  urged,  as  the  pain  keeps  him 
quiet.  Since  commencing  this  treatment  I  am  so  w-ell  satisfied  with 
it,  that  I  have  almost  given  up  the  other  antiphlogistics  ;  cups,  leeches, 
mercurial  ointment,  etc.  When  the  vesicles  formed  by  the  iodine 
dry  up,  you  apply  more.  Derivation  to  the  intestinal  canal  by  saline 
purgatives  aids  the  treatment,  as  it  does  in  all  acute  inflammations. 
Some  surgeons  greatly  praise  the  local  application  of  ice  at  the  com- 
mencement of  the  disease.  Should  suppuration  nevertheless  occur, 
and  distinct  fluctuation  be  felt  at  the  thinnest  part  of  the  skin,  we 
may  make  several  openings  in  such  a  way  that  the  pus  shall  escape 
without  being  pressed  out ;  then  the  swelling  iisually  subsides  cjuick- 
ly ;  it  is  most  favorable  when  the  fever  ceases  early  and  the  disease 
becomes  chronic.  If  the  fever  continues,  the  suppuration  remaina 
profuse,  the  pains  do  not  cease.  We  may  try  to  relieve  this  condi- 
tion by  continued  applications  of  bladders  of  ice,  with  which  we  also 
try  to  alleviate  any  mflammations  of  the  joint  that  may  occur.  I  have 
also  derived  great  advantage  from  the  ajoplication  of  a  fenestrated 
plaster-splint,  which  should  be  supported  w  ith  hoops  on  account  of 
the  large  openings  that  must  be  made  in  it ;  in  cases  where  there  is 
detachment  of  the  epiphysis,  it  is  absolutely  necessary  that  the  limb 
should  be  fixed,  if  only  to  render  the   dailj^  dressing   less  painful 


330     ACUTE  INFLAMMATIONS  OF  THE  BONES,  PERIOSTEUM,  ETC. 

Many  surgeons  do  Qot  follow  this  treatment,  which  is  backed  by  a 
series  of  favorable  cases.  Some  recommend  making  large,  deep  in- 
cisions down  to  the  bone  at  the  very  start,  or  at  least  as  soon  as 
suppuration  begins.  Such  extensive  wounds  are  bad  in  feverish  pa- 
tients ;  I  a^i  satisfied  that,  under  these  circumstances,  this  heroic  treat- 
ment renders  the  condition  worse,  it  increases  the  predisposition  to 
pyaemia.  The  idea  that  in  acute  osteomj^elitis  exarticulation  should 
be  made  at  once,  as  otherwise  pyremia  is  unavoidable,  seems  to  me 
even  more  erroneous.  This  belief  is  certainly  untrue,  and  under 
such  circumstances  amputation  is  not  indicated,  first,  because  at  the 
onset  the  diagnosis  of  osteomyelitis  is  not  absolutely  certain,  as  the 
case  might  possibly  be  one  of  simple  acute  periostitis ;  secondly,  be- 
cause the  jDrognosis  in  exarticulation  of  large  limbs,  if  done  for  acute 
disease  of  the  bone,  is  always  very  doubtful.  In  acute  periostitis  and 
osteomyelitis,  of  the  tibia  for  instance,  I  should  only  amputate  at  the 
thigh  if  the  suppuration  were  very  excessive,  and  acute  suppm-ation 
of  the  knee-joint  should  occur.  Should  the  disease  aifect  the  femur 
and  run  an  unfavorable  course,  I  should  scarcely  hope  to  save  the  pa- 
tient by  an  operation  so  dangerous  as  amputation  at  the  hip-joint. 
We  may  accomplish  much  by  great  care  of  the  patients,  who  are  gen- 
erally youthful.  A  young  girl  with  osteomyeHtis  and  periostitis  of 
the  tibia  had  sixteen  chills  in  twelve  days,  and  nevertheless  recovered, 
although  part  of  the  tibia  became  necrosed,  and  the  foot  was  anchy- 
losed. 

I  will  here  add  a  few  remarks  about  suppurative  periostitis  of  the 
third  phalanx  of  the  finger,  which  is,  perhaps,  the  place  where  it  most 
frequently  occurs.  As  this  inflammation  in  the  hand  and  fingers  is 
usually  called  panaritium,  this  periostitis  of  the  last  phalanx  is  termed 
panaritium  2^6riostale.  This,  like  any  periostitis,  is  very  painful; 
it  is  a  long  while — sometimes  eight  or  ten  days — ^before  the  pus  per- 
forates oiitward.  The  termination  in  partial  or  total  necrosis  of  the 
phalanx  is  common,  and  cannot  be  prevented  even  by  an  early  in- 
cision, although  we  often  have  to  make  one  to  relieve  the  disagree- 
able, throbbing,  burning  pain,  partly  by  the  loss  of  blood,  partly  by 
splitting  the  periosteum.  As  the  termination  in  suppuration  can 
scarcely  ever  be  avoided,  we  tr}'-  to  induce  it  by  cataplasms,  hantl- 
baths,  etc.,  and  thus  hasten  the  course. 

Thus  far  we  have  only  spoken  of  acute  inflammation  of  the  peri- 
osteum, and  medulla  of  the  long  bones,  but  have  not  considered  that 
of  the  spongi/  boiies.  Nor  have  Ave  considered  the  question  of  in- 
flammation of  the  bone-substance  proper.  Is  there  such  a  thing  ?  1 
think  this  must  be  answered  in  the  negative,  for  I  consider  that  dila* 


ACUTE   PERIOSTITIS.  331 

tat  ion  of  the  vessels,  cell-infiltration,  and  serous  imbibition  of  the  tis- 
sue, in  their  various  combinations,  constitute  the  essence  of  acute  in 
flammations.  In  the  compact  bone-substance  (as  in  the  cortical  layer 
of  a  long  bone)  all  these  requirements  cannot  occur.  In  many  places 
at  least,  the  capillary  vessels  are  so  closely  embedded  in  the  Haver- 
sian canals  that  they  cannot  dilate  much  ;  a  certain  amount  of  serous 
infiltration  of  the  bone  is  imaginable ;  but  the  firm  bone-substance 
cannot  possess  much  capability  of  swelling.  If  the  term  inflamma- 
tion be  made  so  general  as  to  include  every  quantitative  and  qualita- 
tive disturbance  of  nutrition,  it  would  be  a  very  peculiar  view,  in 
Avhich  I  do  not  participate.  Every  tissue  attacked  by  inflammation 
changes  its  j^hysical  and  chemical  nature,  and  in  acute  inflammation 
of  the  soft  parts  this  takes  place  rapidly ;  the  connective  tissue  es- 
pecially is  quickly  changed  to  a  gelatinous,  albuminous  substance  ;  the 
tissue  of  the  cornea  and  cartilage  may  also  change  very  quickly.  For 
chemical  reasons  this  is  impossible  in  bone  ;  time  is  required  for  the 
cLalky  salts  of  the  bone  to  dissolve,  and  the  bone-cartilage  left  deli- 
quesces like  other  tissue.  Hence,  inflammation  of  comjoact  bony  tis- 
sue, severe  though  it  be,  cannot  run  its  course  very  rapidly ;  it  always 
takes  a  long  while.  The  above  refers  only  to  compact  bone-substance ; 
spongy  bones  may  readily  become  inflamed,  that  is,  there  may  be  in- 
flammation of  the  medulla  contained  in  the  spongy  bones  which  has 
the  same  peculiarities  as  that  of  the  long  bones,  only  it  is  not  collected 
together  as  it  is  in  them,  but  it  is  distributed  in  the  meshes  of 
the  bones ;  each  space  contains  many  capillaries,  connective  tissue, 
fat-cells,  and  nerves ;  acute  inflammation  of  the  spongy  bones  first  oc- 
curs in  these  interspaces,  and  gradually  extends  to  the  bone  proper. 
^^Tiat  is  called  acute  ostitis  of  a  spongy  bone  is  at  first  only  acute  os- 
teomyelitis. This  when  idiojDathic  is  rarely  acute,  but  is  usually 
chronic,  sometimes  subacute.  On  the  other  hand,  there  is  a  traumatic 
acute  osteomyelitis  of  spongy  bones,  about  which  we  shall  here  say 
something,  although  we  have  discussed  its  more  important  features 
when  treating  of  suppuration  of  bone.  Imagine  an  amputation 
wound  close  below  the  knee :  the  tibia  has  been  sawed  through  its 
upper  spongy  part ;  traumatic  inflammation  occurs  in  the  medulla  of 
the  bone,  in  the  meshes  of  the  bone-substance,  with  proliferation  o\ 
vessels,  cell-infiltration,  etc. ;  this  leads  to  development  of  granula- 
tions, which  grow  out  from  the  medulla  and  soon  form  a  granulating 
surface ;  this  cicatrizes  in  the  usual  manner.  But  subsequently,  if 
you  have  a  chance  to  examine  such  a  stump,  you  find  that,  at  the  sawed 
surface  of  the  bone,  the  meshes  are  filled  with  bone-substance,  and 
the  outer  layer  of  the  spongy  bone  is  transformed  to  compact  bon}' 
substance ;  that  is,  the  cicatrix  in  the  bone  has  ossified.     This  is  the 


332     ACUTE  IXFLAMMATIOXS  OF  THE  BONES,  PERIOSTEUM,  ETC, 


normal  termination  not  oulj  of  traumatic  but  of  spontaneous  ostitis ; 
the  bony  cicatrix  ossifies.  There  may  also  be  suppuration,  putrefac- 
tion of  the  medulla  of  spongy  bones,  as  in  long  bones ;  osteophlebitis 
and  its  consequences  may  also  occur.  In  the  lectvu'c  on  suppuration 
of  bone  (p.  ^28)  and  healing  of  open  fractures  we  treated  fully  of  the 
changes  which  occur  affer  the  bone  has  lost  its  periosteum,  of  the 
development  of  granulations  on  the  surface  of  compact  bone-sub- 
stance, and  of  the  accompanying  superficial  necrosis. 

Here  I  will  merely  add  that  we  sometimes  meet  multiple  inflam- 
mations of  the  bones  as  we  do  multiple  acute  inflammations  of  the 
soft  parts  (acute  polyarticular  rheumatism) ;  these  may  occur  simul- 
taneously in  the  two  corresponding  bones  of  the  lower  extremities, 
or  may  follow  each  other ;  e.  g.,  osteomyelitis  of  the  tibia,  suppura- 
tive inflammation  of  the  knee-joint,  osteomyelitis  of  the  femur,  puru- 
lent inflammation  of  the  hip-joint ;  in  one  case  there  was  also  osteo- 
m^'^elitis  of  the  other  femur  and  purulent  coxitis  of  the  other  side. 
Even  such  cases  may  possibly  terminate  favorabl}',  but  this  is  very 
rare ;  they  usuall.y  end  fatally. 

My  saying  that  I  could  not  imagine  an  acute  inflammation  of 
hony  tissue  has  caused  some  misunderstanding.  In  acute  inflam- 
mation of  bone  no  changes  are  observed  in  the  (fully  developed) 
osseous  tissue,  but  only  in  the  medulla  and  periosteum  and  their 
vessels.  I  do  not  underestimate  the  chemical  changes  (disturb- 
ances of  nutrition)  which  go  on  in  the  tissues  during  inflammation  ; 
but  we  do  not  know  them  :  we  only  conclude  they  occur  from  the 
changes  we  see  in  the  tissues.  AVe  see  that  inflamed  connective  tissue 
swells,  becomes  cloudy,  is  infiltrated  by  wandering  cells,  softens, 
and  finalh'  breaks  down  into  pus  ;  and  all  this  occurs  within  a  few 
days.  In  bony  tissue  we  see  none  of  these  changes  ;  we  do  not  see 
that  it  swells  in  acute  inflammation,  or  that  its  interspaces  (excejjt 
the  Haversian  canals)  fill  with  wandering  cells  ;  and  we  know  that 
it  does  not  suddenly  break  down  into  pus.  "VYe  only  know  one  ter- 
mination  of  acute  inflammation  of  bone,  that  is,  death — necrosis  ; 
besides  this,  it  may  pass  on  into  chronic  inflammation.  Hence  we 
can  only  say  it  is  probable  that  in  acute  inflammation  of  bone 
changes  of  nutrition  occur,  as  in  that  of  connective  tissue  ;  but 
there  is,  or  rather  from  the  nature  of  bone-tissue  there  can  be,  no 
morphological  expression  for  this  change. 

[Osteomyelitis  may  occur  spontaneously,  or  after  "  cold,"  or  sec- 
ondarily in  the  vicinity  of  acutely-inflamed  joints,  or  as  a  result  of 
severe  crushing  or  subcutaneous  fractures  ;  also  after  acute  infec- 
tious diseases,  especially  typhus,  scarlatina,  and  measles,  or  after  in- 
flammations of  any  part  of  the  body.    But  it  is  probable  that  neither 


ACUTE   PERIOSTITIS.  333 

catcliiiig  cold  nor  injury  is  the  sole  actual  cause,  but  that  it  is  due 
rather  to  a  general  or  local  infection,  like  articular  rheumatism  and 
certain  phlegmons,  though  we  cannot  always  discover  the  source  of 
the  infection.  After  Roser  and  Luche  advanced  the  theory  that 
this  disease  was  of  infectious  origin,  Kocher,  Itosenbach,  Busch, 
and  others,  showed  experimentally  that  acute  suppurative  osteomy- 
elitis could  not  be  induced  by  chemical  or  mechanical  injury,  but 
resulted  at  once  if  putrefying  matters  were  applied  to  fresh  wounds 
of  bone.  The  affection  does  not  seem  to  be  induced  by  any  specific 
poison,  but  may  be  excited  by  a  variety  of  putrid  matters  already 
in  the  body,  or  which  may  have  entered  through  the  alimentary 
canal,  if  an  injury  or  irritation  of  the  medulla  of  bone  has  been 
developed  in  any  way.  Rarely,  several  bones  are  attacked  at  the 
same  time  ;  we  have  a  mxdtipU  osteomyelitis  ;  we  do  not  know  if 
this  is  due  to  an  infection  acting  at  the  same  time  on  various  points, 
or  to  passage  of  the  poison  from  the  point  j)i"iEnarily  affected.  On 
examining  the  diseased  bone,  we  find  scattered  in  the  medulla  nu- 
merous punctate  abscesses  comiDOsed  of  pus-corpuscles  and  numer- 
ous micrococci,  or  larger  collections  of  putrid  pus  containing  also 
quantities  of  large  multigranular  cells,  proliferating  fatty  tissue 
according  to  liosenhach,  and  spindle-shaped  elements.  If  infection 
has  occurred  in  any  way,  there  will  be  acute  suppurations  leading 
to  decomposition  of  the  medulla  in  the  worst  cases.  The  peri- 
osteum becomes  diseased  at  once,  or  secondarily  ;  either  without 
direct  connection  with  the  primary  abscess,  or  after  it  has  opened. 
Often  the  neighboring  joints  are  affected,  either  at  the  onset  or 
later.  There  are  also  inflammations  of  the  serous  membranes,  sup- 
purative pleuritis  and  pericarditis,  abscesses  in  the  lungs,  liver,  etc. 
The  disease  proves  fatal  with  typhoid  symptoms  and  coma  by 
general  septic  infection,  or  by  pyemia  from  absorption  of  pus,  or 
lastly,  after  a  protracted  course  from  secondary  inflammation  of 
internal  organs.  Although  between  the  severe  rapidly  fatal  cases 
and  the  milder  forms  of  osteomyelitis  there  is  no  essential  etio- 
logical difference,  those  that  are  hopeless  from  the  first  are  fortu- 
nately rare,  and  in  some  places  never  occui".  Sometimes  in  the 
joint  implicated  there  is  development  of  gas,  even  before  the 
abscess  has  opened  ;  this  is  a  bad  sign.  The  pus  in  bones  affected 
with  osteomyelitis  often  contains  fat-globules  from  the  medulla 
and  quantities  of  micrococci,  which  are  also  found  in  purulent 
thrombi  of  osseous  veins,  metastatic  deposits  in  the  kidneys,  etc. 

While  acute  osteomyelitis  comes  from  infection  of  the  blood- 
vessels of  the  bone  by  septic  matters,  there  is  another  form  of 
ostitis  and  osteomyelitis,  probably  also  due  to  entrance  of  a  foreign 


334       ACUTE  INFLAMMATION  OF  TifE  BONES,  PERIOSTEUM,  ETC. 

body  into  the  vessels,  but  whose  action  is  chiefly  mechanical.  This 
peculiar  and  etiologically  very  interesting  form,  described  by  Eng- 
liscli  and  Gmsenhauer,  is  ostitis  of  turners  of  mother-of-pearl  ; 
these  workmen  are  mostly  young,  and  live  in  an  atmosphere 
impregnated  with  very  fine  powder  of  mother-of-pearl  ;  they  are 
frequently  attacked  by  painful,  multiple  inflammations  of  the 
diaphyses  of  the  long  bones,  with  marked  swelling  of  the  peri- 
osteum, which  have  a  subacute  course,  and  according  to  present 
experience  never  lead  to  suppuration.  The  result  of  this  osteoperi- 
ostitis is  complete  recovery  ;  at  most  there  is  left  some  thickening 
of  the  periosteum,  but  rela])ses  occur  if  patients  resume  their  occu- 
pation. From  chemical  and  microscopical  examination  of  the 
mother-of-pearl  dust,  and  clinical  observations,  Gussenhauer  offers 
the  following  hypothesis  as  to  the  genesis  of  this  disease  :  Besides 
inorganic,  mother-of-pearl  dust  has  organic  constituents,  which,  be- 
ing inhaled  into  the  lungs,  pass  into  the  circulation  ;  the  molecules 
of  the  organic  constituents  are  of  such  a  size  that  they  stick  in  the 
small  arteries  of  the  diaphyses,  and  there  form  emboli  and  in- 
duce inflammation  of  the  bone  and  secondarily  of  the  periosteum. 
In  the  diaphyses  of  the  long  bones  there  are  minute  arteries  sup- 
plying a  circumscribed  territory  (terminal  arteries  of  Cohnheim). 
This  explanation  might  account  for  the  sudden  painful  occurrence 
of  the  disease,  and  the  subsequent  local  swelling,  as  well  as  its 
being  confined  to  the  diaphysis,  which  is  the  only  seat  of  the 
peculiar  arrangement  of  the  vessels. 

A  belief  in  the  infectious  nature  of  osteomyelitis  will  greatly 
influence  the  treatment.  If  there  be  fever,  with  morning  remis- 
sions, give  fifteen  to  twenty  grains  of  quinine  or  ninety  to  one 
hundred  and  eighty  grains  of  salicj^late  of  soda  daily  during  the 
remission.  If  certain  of  the  diagnosis,  the  abscess  should  be  opened 
early,  with  antiseptic  precautions.  An  incision  should  be  made 
down  to  the  bone  at  the  tender  spot,  and,  if  no  pus  be  found  under 
the  periosteum,  an  opening  should  be  made  in  the  bone  with  a 
trephine  or  chisel  ;  the  pus  should  be  washed  out,  the  wound  dis- 
infected, and  an  antiseptic  dressing  applied.  If,  instead  of  being 
circumscribed,  the  pus  be  infiltrated  through  the  bone,  opening  the 
medullary  cavity  will  probably  do  little  good. 

The  treatment  of  ordinary  subacute  periostitis  is  more  simple 
and  easy  ;  we  may  quietly  await  suppuration  and  incise  when 
fluctuation  is  evident  ;  till  then  use  moist- warmth,  rest,  elevation, 
and  moderate  compression  of  the  limb.  When  pus  appears  at  any 
point,  open  with  antiseptic  precautions,  drain,  and  apply  Lister's 
dressing  till  the  cavity  fills  up.     Fixation  of  a  limb  affected  with 


INFLAMMATIOX   OF   THE   JOIXTS,  335 

acute  osteomyelitis  is  the  more  important  the  more  acute  and 
painful  the  process,  and  it  is  particularly  necessary  when  there  is 
detachment  of  an  epiphysis.  In  such  cases  plaster  dressings  were 
formerly  applied,  but  for  Lister''s  dressing  splints  and  starched 
gauze  (organtin)  are  better,  or  else  permanent  extension  and  gutta- 
percha splints. 

Under  suitable  treatment,  after  evacuation  of  the  pus,  fever  is 
arrested,  swelling  disappears  from  the  limb,  and  the  disease  passes 
into  a  chronic  stage.  During  this  time  moderate  discharge  of  pus 
continues,  and  gradually  the  necrosed  portion  of  bone  becomes 
detached  from  the  healthy  part.  This  constitutes  the  process  of 
repair  and  restitution  :  on  the  one  hand,  the  sequestrum  is  elimi- 
nated ;  on  the  other  hand,  the  loss  of  substance  in  the  bone  is  re- 
placed. Suppurative  inflammation  of  joints  requii'es  special  treat- 
ment, of  which  we  will  treat  in  the  next  chapter.] 


We  now  come  to  acute  inflamination  of  the  joints.  As  we 
have  previously  spoken  of  traumatic  articular  inflammations,  you 
already  know  some  of  the  peculiarities  of  diseased  joints.  You 
also  know  that  serous  membranes  have  a  great  tendency  to  excrete 
fluid  exudation  when  irritated,  but  that  this  exudation  may  also 
contain  pus,  if  the  inflammatory  irritation  be  very  intense.  As 
there  is  a  pleurisy  with  effusion  of  sero-fibrinous  fluid  (the  ordinary 
form),  and  a  variety  with  purulent  effusion  (so-called  empyema), 
so  in  joints  we  speak  of  sei'ous  synovitis,  or  hydrops,  and  of  puru- 
lent synovitis,  or  empyema  ;  both  forms  of  the  disease  may  be 
either  acute  or  chronic,  and  they  induce  various  diseases  of  the 
cartilage,  bone,  articular  capsule,  jaeriosteum,  and  surrounding  mus- 
cles. You  will  see  that  it  is  always  more  complicated  with  these 
diseases  the  more  complicated  the  affected  part  is.  Of  late,  great 
importance  has  been  attached  (especially  by  French  surgeons)  to 
speaking,  first,  of  diseases  of  the  synovial  membrane,  then  of  those 
of  the  cartilage,  articular  capsule,  and  bone,  corresponding  to  the 
anatomical  conditions.  Correct  as  this  division  would  be,  if  it 
were  only  a  question  of  representing  the  pathological  anatomical 
changes,  it  is  of  little  use  in  practice.  The  surgeon  always  views 
inflammation  of  the  joint  as  a  whole,  and,  although  he  should  know 
which  part  of  the  joint  suffers  most,  this  is  only  a  part  of  what  he 
should  know  ;  course,  symptoms,  and  constitutional  state,  equally 
demand  his  attention,  and  determine  the  treatment.  Hence  the 
entire  clinical  appearance  will  determine  the  divisions  of  this,  as  of 
many  other  diseases. 


336  INFLAMMATION   OF   THE   JOINTS. 

At  present  we  are  speaking  only  of  apparently  spontaneous  acute 
inflammations  of  the  joints.  In  many  cases  they  are  evidently  due  to 
catchino-  cold,  in  other  cases  their  causes  are  obscure.  Some  of  the  more 
subacute  cases  are  of  metastatic  nature  and  appear  as  pyaemia.  But 
at  present  we  shall  speak  only  of  the  idiopathic  inflammations,  which,, 
in  contradistinction  to  the  traumatic,  are  termed  7-Iieiimatic,  as  they  are 
often  due  to  cold.  Patients  requiring  your  aid  for  such  acute  inflam- 
mations of  the  joints,  -will  present  somewhat  different  symptoms.  If, 
for  illustration,  we  agam  take  the  knee-joint,  you  will  have  about  the 
folloAving  jjicture :  A  strong,  otherwise  healthy  man  has  taken  to  bed» 
because  for  a  day  or  two  his  knee  has  been  swollen,  hot,  and  painful ; 
vou  find  this  on  examining  the  knee,  you  also  find  distinct  fluctuation 
in  the  joint,  and  that  the  patella  is  somewhat  lifted  up,  and  always 
rises  again  if  pressed  down ;  the  skin  over  tlie  joint  is  not  red  ;  the 
patient  lies  "v^-ith  his  leg  stretched  out  in  bed,  has  no  fever,  and,  if  you 
ask  him,  can  bend  and  extend  the  knee,  though  with  some  difiiculty. 
You  here  have  an  acute  serous  synovitis,  or  hydrops  genu  acutus.  The 
anatomical  condition  of  the  knee  is  as  follows  :  the  synovial  membrane 
is  slightly  swollen  and  moderately  vascular ;  the  articular  cavity  full 
of  servmi,  which  has  mingled  with  the  s^-novia ;  there  are  a  few  flocculi 
of  fibrine  in  the  fluid,  the  rest  of  the  joint  is  healthy.  Anatomically 
the  state  is  just  like  a  subacute  bursitis  tendinum  or  a  moderate 
pleurisy.  This  disease  is  generally  cured  without  difficulty  ;  quiet,  re- 
peatedly painting  with  tinctui'e  of  iodine,  or  a  few  blisters,  or  com- 
pression with  wet  bandages,  suffice  to  remove  the  affection  in  a  few 
days,  or  at  least  to  take  off  its  acuteness ;  all  the  symptoms  of  the 
acute  inflammation  may  subside,  the  patient  may  go  about  with 
scarcely  any  difficulty,  but  there  remains  too  much  fluid  in  the  joint, 
a  hydrops  chronicus  of  the  joint  is  left. 

You  may  be  called  to  another  patient  with  inflammation  of  the 
knee-joint.  A  few  days  previously  the  young  man  has  caught  cold  ; 
soon  after  this  his  knee  has  begun  to  pain,  high  fever  has  come  on, 
perhaps  a  heavy  chill ;  the  joint  has  constantly  grown  more  painful. 
The  patient  hes  in  bed,  with  the  knee  flexed  so  that  the  thigh  is 
strongly  rotated  outward  and  abducted ;  he  resists  every  attempt  t(? 
move  the  leg,  as  it  causes  him  1  errible  pain.  The  knee-joint  is  greatly 
swollen  and  feels  hot,  but  there  is  no  fluctuation,  tlie  skin  is  oedematous 
and  red  about  the  knee,  the  whole  leg  also  is  oedematous  ;  on  account 
of  the  pain  it  is  impossible  to  extend  the  knee  or  to  flex  it  more. 
What  a  contrast  to  the  former  case !  If  you  have  a  chance  to  examine 
the  joint  in  this  stage,  you  find  great  swelling  of  the  s)'no\'ial  mem- 
brane ;  it  is  very  red,  puffy,  and  microscopically  appears  infiltrated 
with  plastic  matter  and  serum.     In  the  joint  there  is  usually  a  little 


ACUTE  INFLAMMATIONS  OF  THE  BONES,  PERIOSTEUM,  ETC.     337 

floccixlent  pus  mixed  witla  the  sj'novia,  there  may  also  be  pure  pus. 
The  surface  of  the  cartilage  looks  cloudy,  and  microscopically  perhaps 
shows  little  change  beyond  turbidity  of  the  hyaline  substance ;  possi- 
bly the  cartilage  cavities  are  somewhat  enlarged  and  filled  with  an  un- 
usual number  of  cells.  The  tissue  of  the  articular  capsule  is  oedematous. 
Here  you  have  a  purulent  very  acute  synovitis^  in  which  the  cartilage 
threatens  to  participate ;  should  the  disease  continue,  and  the  pus  in 
the  joint  increase,  you  may  correctly  call  it  empyema  of  the  joint. 

The  difference  between  the  first  and  second  forms  of  acute  syno- 
^dtis  is  essentially  that,  in  the  second,  the  tissue  of  the  s3movial 
membrane  is  deeply  affected,  while  in  the  first  the  increased  secretion 
is  the  chief  feature.  Between  these  two  forms  are  subacute  cases,  in 
wliich  the  secretion  becomes  purulent  and  collects  in  great  quantity, 
without  there  being  any  great  destruction  of  the  synovial  membrane. 
K.  VolJcmami  calls  this  "  catarrhal  inflammation  "  of  the  joint ;  it  is 
somewhat  more  painful  than  ordinary  acute  hydrops,  from  which  the 
catarrhal  purulent  form  may  proceed,  though  this  is  rarely  the  case. 
I  have  already  said  what  was  necessary  about  the  course  and  treat- 
ment of  acute  hydrops.  The  course  and  results  of  the  more  paren- 
chymatous synovitis,  which  is  predisposed  to  suppuration,  depend 
greatly  on  when  the  treatment  is  begun  and  what  it  is.  Usually  a 
few  leeches  are  applied  and  then  the  joint  is  poulticed,  from  an  idea 
of  the  old  school,  that  rheumatic  articular  inflammations  should  be 
treated  with  warm  applications.  I  consider  leeches  almost  useless  in 
these  affections  ;  perliaps  there  may  be  a  question  about  keeping  the 
limb  warm,  for  this  is  often  pleasant  to  the  patient;  it  alleviates  the 
pain  in  inflammations  of  the  serous  membranes,  often  more  so  than  cold 
does ;  at  least  the  latter  must  act  for  some  time  before  having  a  favor- 
able effect.  I  explain  this  as  follows  :  The  warm  applications  induce 
fluxion  to  the  vessels  of  the  skin,  and  thus  empty  those  of  the  s}tio- 
vial  membrane  ;  but  this  effect  is  not  long  continued ;  fluxion  to  the 
inflamed  deeper  parts  returns  again,  and  is  stronger  than  to  the  artifi- 
cially-warmed skin.  On  application  of  a  large  bladder  of  ice  to  the 
joint,  the  vessels  of  the  skin  contract,  and  perhaps  drive  the  blood  to 
the  vessels  of  the  inflamed  part  more  strongly  than  before,  till  gradu- 
ally the  cold  has  its  effect  on  these  also,  and  if  the  cold  continues  the 
effect  becomes  permanent.  It  seems  more  rational  always  to  use  cold 
in  these  cases ;  in  very  acute  inflammations  of  the  joint  the  employ- 
ment of  ice-bladders  has  also  proved  very  practical.  Besides  using 
cold,  you  may  also  induce  active  derivation  to  the  skin  by  strong  tinc- 
tm-e  of  iodine,  or  by  a  large  blister.  But  besides  these  remedies  it  is 
most  important  to  bring  the  joint  into  a  proper  position  and  keep  it 
there,  for,  if  we  do  not  obtain  a  perfect  cure,  and  the  joint  remains 
23 


338  INFLAMMATION   OF   THE   JOINTS. 

stiff,  the  flexed  jDOsition  of  the  knee,  which  is  so  frequent,  is  a  very 
unfortunate  addition  to  the  stiffness,  as  it  renders  the  limb  nearly 
if  not  entirely  useless. 

The  mali^osition  should  be  relieved  ;  this  should  be  done  for 
each  joint  in  such  a  way  that  in  case  of  complete  stiffness  its  posi- 
tion shall  be  most  favorable.  The  hip  and  knee-joint  should  be 
extended,  the  foot  and  elbow  at  right  angles  ;  the  wrist  and  shoul- 
der do  not  get  out  of  position  ;  the  former  usually  remains  extended, 
the  latter  usually  takes  such  a  position  that  the  arm  lies  against  the 
thorax.  There  is  very  great  difference  in  the  frequency  of  acute 
disease  in  the  different  joints  ;  the  knee  is  most  frequently  affected, 
then  the  elbow  and  wrist  ;  acute  inflammation  of  the  hip,  shoulder, 
and  ankle,  is  rare.  Acute  articular  inflammations  are  more  frequent 
in  young  persons  than  in  old,  but  hardly  ever  occur  in  children. 
But,  to  return  again  to  the  improvement  of  the  position  of  the 
joint :  you  will  tell  me  this  is  impossible.  Chloroform  is  here  use- 
ful ;  this  remedy  has  become  most  important  in  the  treatment  of 
inflammations  of  the  joints.  You  narcotize  the  patient  deeply,  and 
can  then  move  the  limb  without  trouble  ;  the  muscles,  which  pre- 
viously contracted  on  the  least  touch,  now  yield  without  difticulty. 
If  we  continue  with  our  former  hyiiothetical  case,  you  extend  the 
knee,  envelop  it  in  a  thick  layer  of  wadding,  and  apply  a  plaster- 
splint  from  the  foot  to  the  middle  of  the  thigh.  When  the  patient 
awakes,  he  will  at  first  complain  of  severe  pain  ;  give  him  a  quarter 
of  a  grain  of  morphia  and  ajiply  one  or  two  bladders  of  ice  over  the 
plaster-splint  to  the  knee ;  the  cold  acts  slowly,  but  finally  proves 
effective,  and  in  twenty-four  hours  the  patient  feels  tolerably  com- 
fortable. The  slight  compression  made  by  the  well-padded  plaster- 
splint  also  has  a  favorable  antiphlogistic  action  ;  if  there  be  fever, 
you  may  give  cooling  medicines  and  saline  purgatives  ;  but  the 
patient  needs  no  further  treatment.  Before  applying  the  dressing, 
you  maj^  have  the  limb  rubbed  with  mercurial  ointment  or  painted 
with  tincture  of  iodine.  It  is  best  to  apply  the  dressing  even  in 
the  most  acute  stage  ;  of  course  it  must  be  done  very  carefully, 
avoiding  any  strangulating  pressure.  Recently  it  has  been  shown 
that,  even  in  very  acute  inflammations  of  the  joints,  surprising  re- 
sults may  be  obtained  by  extension  with  weights.  It  is  very  inter- 
esting to  observe  how  a  continued  moderate  traction  lessens  the 
pain  in  the  joint  and  relaxes  the  muscles.  But  much  depends  on 
the  application  of  the  dressings,  and  I  cannot  too  strongly  urge  on 
you  to  attend  carefully  to  these  apparently  simple  mechanical 
things,  whose  imiDortance  you  will  not  coiTCCtly  estimate  till  thrown 


ACUTE  INFLAMMATION  OF  THE  BONES,  PERIOSTEUM,  ETC.       339 

on  your  own  resoitrces  in  practice,  and  obliged  to  attend  .to  the 
minutest  details  yourself. 

[The  treatment  in  acute  non-traumatic  suppuration  of  joints  has 
changed  greatly  within  a  few  years.  If,  after  fixation  of  the  joint, 
the  intlammation  threatens  j^rogress,  we  may  open  the  joint  freely 
with  antiseptic  precautions,  as  was  described  when  treating  of 
traumatic  cases.  Pus  is  evacuated  and  all  recesses  of  the  synovial 
sac  are  to  be  washed  out  with  a  two-per-cent.  solution  of  carbolic 
acid  ;  the  joint  should  be  drained,  disinfected  with  a  five-per-cent. 
solution  of  chloride  of  zinc,  and  a  Liste7'''s  dressing  applied  ;  then 
the  limb  kept  in  proper  splints.  Instead  of  Lister'^s  dressing,  per- 
manent irrigation  with  J)urow''s  solution  may  be  indicated  ;  in 
patients  wnth  high  fever  this  has  the  advantage  of  being  an  excel- 
lent means  for  reducing  temperature.  By  this  treatment  w'e  may 
succeed  in  curing  the  case  with  a  movable  joint  if  the  articular 
cartilages  have  not  been  destroyed  ;  and  at  any  rate  we  may  pre- 
vent periarticular  abscesses  and  absorption  of  pus.  If  extensive 
suppuration  of  the  soft  parts  has  begun,  permanent  irrigation  is 
particularly  indicated,  but  will  often  prove  ineffectual,  and  amputa- 
tion will  be  necessary.] 

If  called  to  the  case  early,  you  may  sometimes  not  only  arrest  the 
acute  stage  of  the  disease,  but  may  preserve  to  your  patient  a  mov- 
able joint.  But,  even  if  called  late,  the  above  treatment  should  be 
pursued.  If  the  pain  is  relieved  and  the  fever  ceases,  you  may  re- 
move the  dressing  in  a  few  weeks,  for  the  disease  lasts  several  weeks 
under  any  circumstances ;  perhaps  three  to  five  months  may  elapse 
before  the  inflammation  entirely  disappears;  gradually  the  noimal 
condition  and  the  former  mobility  return,  then  the  patient  should  be 
earnestly  warned  against  taking  cold  or  excessive  motion,  for  a  second 
attack  might  not  turn  out  so  well. 

Supposing  the  acute  process  does  not  subside  under  the  treatment 
instituted,  but  continues  to  progress,  it  may  pass  into  a  chronic  form, 
or  remain  acute  ;  we  shall  hereafter  treat  of  the  former  case.  Let  us 
at  present  suppose  that  the  pain,  instead  of  subsiding,  becomes  more 
severe,  and  you  are  obliged  to  split  the  dressing  along  the  front ;  you 
find  the  knee  more  swollen,  distinctly  fluctuating,  and  the  patella 
very  movable,  while  the  patient  has  high  fever.  If  the  disease  con- 
tinues, the  fluctuation  may  extend  farther  and  farther,  upward  to  the 
thigh,  for  instance,  and  the  subcutaneous  cellular  tissue  of  the  thigh 
and  leg  may  participate  in  the  suppuration.  Formerly  this  extension 
was  attributed  to  subcutaneous  bursting,  or  partial  suppuration  of  the 
Bynovial  sacs  around  the  johit,  especially  of  the  large  one  uuder  the 


340  INFLAilMATIOX   OF   THE   JOIXTS. 

tendon  of  the  quadriceps  femoris,  and  of  tlie  bursa  poplltea ;  to  pre- 
vent this  misfortune  it  was  considered  ad\dsable  to  tap  the  joint  with 
a  trocar,  in  the  above  stage  of  the  disease,  to  let  out  most  of  the  pus, 
and  then  carefully  close  the  opening.  From  my  own  experience  I  should 
consider  this  operation  as  rarely  indicated,  for  I  have  convinced  my- 
self, by  careful  examinations  of  patients,  and  occasionally  of  the 
cadaver,  that  these  periarticular  abscesses  in  the  cellular  tissue,  oc- 
curring in  acute  synovitis,  and  also  in  ostitis  of  the  articular  extremi- 
ties, form  separately,  and  break  into  the  joint  late,  if  they  do  so  at 
all.  With  the  development  of  these  abscesses  the  general  condition 
of  the  patient  is  usually  impaired ;  he  has  high  fever,  with  intercur- 
rent chills,  his  cheeks  fall  in,  he  emaciates,  loses  his  appetite,  and 
becomes  sleepless.  Quinine  and  opiuin  finally  lose  their  effect,  and, 
unless  you  amputate  the  thigh  early  enough,  the  patient  dies  from  the 
exhausting  suppuration  and  continued  fever;  perhaps,  also,  he  may 
have  metastatic  abscesses.  If,  by  the  applications  of  ice,  by  one  or 
more  incisions  for  evacuating  the  pus,  by  quinine  and  opium,  you  suc- 
ceed in  breaking  the  acute  stage  of  the  disease,  and  making  it  chronic, 
you  will  not  obtain  a  movable  joint,  but  even  if  it  is  flexed  at  a  right 
angle,  the  leg  will  be  useful ;  this  is  the  best  result  that  we  can  gain 
after  days  and  weeks  of  anxiety  and  care,  if  the  inflanunation  reaches 
the  above  grade.  The  anatomical  changes  in  a  knee-joint  in  this 
stage  of  inflammation  are  as  follows :  The  joint  is  filled  with  thick 
yellow  pus,  mixed  with  fibrinous  flocculi ;  the  synovial  membrane  is 
covered  Avith  dense  purulent  fibrous  rinds,  under  which  it  is  very  red 
and  puff}',  partly  ulcerated ;  the  cartilage  is  partly  broken  down  into 
pulp,  part]\'  necrosed  and  peels  off;  the  bone*  under  it  is  very  red  or 
infiltrated  (osteomyelitis ;  usually  in  these  cases  a  secondary,  rarely  a 
primary  disease). 

The  prognosis  of  this  disease  is  not  very  bad  in  young,  vigorous 
persons,  when  the  proper  treatment  is  resorted  to  early ;  it  is  very 
bad,  almost  absolutely  fatal,  in  old,  decrepit  persons. 


In  the  above  I  have  pictured  to  you  typical  cases  of  the  two  forms 
of  sj-novitis,  the  serous  and  parenchymatous  (purulent),  and  am  satis* 
fied  that  in  practice  you  will  readily  recognize  these  pictures  again ; 
and  you  will  have  no  difficult}-  in  applying  what  has  been  said  of  the 
knee  to  other  joints.  Now  I  must  add  that  there  is  still  another 
acute  or  subacute  form  of  articular  inflammation,  which  offers  some 
peculiarities,  I  refer  to  acute  articular  rheumatism.  This  very  pe- 
culiar disease,  which  will  be  treated  of  more  fully  in  the  lectm-es  on 


ACUTE  IXFLAMilATIOXS  OF  THE  BOXES,  PERIOSTEUM,  ETC.     31] 

aiternal  medicine,  is  characterized  bj  its  attacking  several  joints  at 
once,  and  its  tendency  to  cause  inflammations  of  other  serous  mem- 
branes, such  as  the  pericardium  and  endocardium,  the  pleura,  and 
rarely  the  peritonaeum  and  arachnoid.  This  simultaneous  disease  of 
these  membranes  and  of  the  joints  marks  the  affection  as  one  impli- 
cating the  whole  body  from  the  start ;  indeed,  from  the  importance 
of  the  organ  affected,  the  pericarditis  and  endocarditis  are  often  so 
prominent,  and  so  much  influence  the  treatment,  that  the  surgical 
treatment  of  the  joints  is  a  very  secondary  matter ;  this  is  the  more 
apt  to  be  the  case,  as  this  disease,  although  very  painful,  rarely  proves 
dangerous  to  the  limb  or  to  life.  The  chief  symptoms  of  the  local 
affection,  beyond  which  the  disease  rarely  proceeds,  are,  great  pain  in 
the  joint  on  every  motion  or  touch,  oedema  of  the  surrounding  soft 
parts,  and  rarely  redness  of  the  skin.  From  the  few  autopsies  that 
have  been  made,  it  appears  that  the  synovia  increases  somewhat,  is 
sometimes  mixed  with  flocculi  of  pus,  and  the  synovial  membrane  is 
swollen  and  red ;  the  cartilage  is  seldom  implicated  ;  the  collection 
of  fluid  is  not  often  so  great  as  to  cause  fluctuation.  Acute  rheuma- 
tism is  very  frequent,  but  it  is  rarely  fatal,  so  that  the  pathological 
anatomical  appearances  are  little  known.  From  all  the  symptoms  of 
this  disease,  it  is  evidently  a  specific,  limited  disease,  of  a  peculiar 
character,  but  with  a  course  so  atypical,  and  causes  so  obscure,  that 
its  actual  character  has  not  yet  been  determined.  I  have  my  doubts 
whether,  besides  this  polyarticular,  we  can  speak  of  a  monarticular 
acute  rheumatism,  for  it  is  just  the  multiplicity  of  the  points  of 
inflammation,  and  their  slight  tendency  to  suppurate,  that  charac- 
terize the  disease  ;  at  all  events,  I  should  not  consider  an  inflammation 
limited  to  one  joint  as  a  symptom  of  acute  rheumatism,  unless  pleu- 
risy, pericarditis,  or  some  other  complication  peculiar  to  rheumatism, 
also  occurred  ;  should  none  of  these  come  on,  the  disease  is  purely  local, 
a  simple  inflammation  of  the  joint,  which  is  probably  called  rheumatic 
simply  because  it  is  supposed  to  be  due  to  catching  cold.  In  acute 
rheumatism,  the  resolution  of  the  articular  inflammation  and  the  res- 
toration of  the  joint  to  its  functions  are  so  common  that  we  rarely  see 
any  other  termination.  That  the  disease  is  tedious,  and  generally 
lasts  six  or  eight  weeks,  is  not  so  much  due  to  the  duration  of  the 
affection  in  a  single  joint  as  to  its  attacking  first  one  joint,  then  an- 
other, and  exacerbations  readily  occurring  in  joints  that  had  recov- 
ered ;  thus  the  disease  proves  tedious,  both  for  physician  and  patient, 
and  the  greatest  watchfulness  and  care  are  necessary  to  avoid  all 
(Sources  of  injury  that  may  again  arouse  the  disease.  It  is  exceedingly 
rare  for  one  of  the  affected  joints  to  go  on  to  intense  suppuration  or 
empyema ;  more  frequently,  in  spite  of  the  subsidence  of  the  disease, 


342  INFLAMMATION   OF   THE   JOINTS. 

a  joint  remains  stiff  and  painful,  and  passes  into  a  state  of  chronic 
inflammation.  You  see  that  the  prognosis  of  this  disease,  as  far  as  it 
concerns  the  joint,  may  be  called  very  favorable ;  without  any  inter- 
ference from  the  johysician,  the  joint-inflammations  generally  inin  a 
favorable  course.  Hence  all  that  we  do  for  the  local  disease  is  to  en- 
velop the  joint  in  wadding,  tow,  oakum,  or  wool,  to  protect  it  from 
changes  of  temperature.  Mild  cutaneous  irritants  and  painting  with 
tincture  of  iodine  may  also  be  useful.  For  alleviating  the  pain  in  the 
joints  and  hastening  the  course  of  the  disease,  Stromeyer  and  others 
recommend  the  employment  of  bladders  of  ice,  and  generally  keeping 
the  joint  cool,  rather  than  warm.  But  I  think  this  treatment  will  find 
few  disciples,  for  it  is  quite  troublesome,  and  experience  shows  that 
the  articular  inflammations  get  on  well  without  such  applications. 
Internally,  we  rnay  give  diuretics,  diaphoretics,  or  cooling  salts ;  in 
heart-aff"ections,  local  antiphlogistics,  digitalis,  etc.,  are  indicated,  as 
will  be  taught  you  more  particularly  in  special  pathologies,  and  in  the 
medical  clinics. 

Next  to  acute  rheumatism  comes  acute  arthritic  inflammation  of 
the  joints.  The  attack  of  podagra  or  chiragra  is  also  specific  and 
belongs  to  true  gout ;  here,  also,  the  articular  inflammation  is  an  acute 
serous  synovitis,  but  with  xevy  little  secretion  of  fluid  in  the  joint. 
But  one  thing  peculiar  to  acute  arthritic  inflammation  is  the  never- 
failing  coincident  inflammation  of  the  surrounding  parts  :  the  peri- 
osteum, sheaths  of  the  tendons,  but  especially  of  the  skin ;  this 
always  reddens,  becomes  ghstening  and  tense,  as  in  erysipelas,  and  is 
very  painful ;  it  even  desquamates  occasionally  after  the  attack. 
Acute  arthritic  articular  inflammation  is  far  more  painful  than  rheu- 
matic. We  shall  hereafter  speak  of  the  treatment  of  arthritis  and  the 
arthritic  diathesis. 


There  is  still  another  variety  of  acute  articular  inflammation,  the 
metastatic,  about  which  we  shall  have  something  more  to  say  when 
treating  of  j^yasmia.  Acute  or  subacute  metastatic  inflammation  of 
the  joint  is  visually  at  first  serous,  but  soon  purely  suppurative  syno- 
vitis.    Several  forms  may  be  distinguished  : 

1.  Gonorrhoeal  inflammation  of  the  joints.  This  occurs  in  men 
sufi'ering  from  gonorrhoea ;  occasionally,  also,  it  occurs  after  the  intro- 
duction of  bougies  into  the  urethra  ;  it  attacks  the  knee-joint  almost 
exclusively.  Some  authors  assert  that  it  is  especiallj^  apt  to  develop 
when  the  gonorrhoea  is  arrested  suddenly.  This  is  not  my  o^vn  ex- 
perience. In  proportion  to  the  frequency  of  gonorrhoea,  it  is  very 
rare  but  I  have  seen  it  quite  frequently  when  a  patient  with  active 


ACUTE  INFLAMMATIONS  OF  THE  BOXES,  PEFJOSTEUM,  ETC.     343 

^onorrlicBa  has  caught  cold.  Tlie  incomprehensible  connection  be- 
tween purulent  catarrh  of  the  urethra  and  inflammations  of  the  knee- 
joint  might  be  denied,  and  the  simultaneous  occurrence  of  the  two 
diseases  be  considered  as  accidental ;  but  the  experience  of  too  many 
surgeons,  and  also  cases  where  inflammations  of  the  knee-joint  occur 
after  other  irritations  of  the  urethra  (as  by  bougies),  speak  in  its 
favor.  Gonon-hoeal  gonarthritis  usually  attacks  both  sides,  and  is  a 
subacute  serous  synovitis,  which  generally  soon  disappears  under 
proper  rest,  avoidance  of  new  irritation  of  the  urethra,  blisters,  tinc- 
ture of  iodine,  and  slight  compression  of  the  joint ;  and,  after  reab- 
sori^tion  of  the  fluid,  it  ends  in  perfect  cure.  But  irritability  of  the 
joint  is  apt  to  remain,  and  not  unfrequently  the  same  person  getting 
another  gonorrhoea  is  again  attacked  with  inflammation  of  the  joints. 
In  some  cases  chronic  articular  rheumatism  is  said  to  follow  conor- 

o 

rhoeal  gonarthritis. 

2.  Pi/CBmic  inflammation  also  occurs  very  frequently  in  one  knee, 
as  well  as  in  the  ankle,  shoulder,  elbow,  and  Avrist ;  rarely  in  the  hip. 
It  is  a  pure  purulent  synovitis,  subsequently  accompanied  by  suppu- 
ration of  the  periarticular  cellular  tissue,  but  usually  with  subacute 
course,  and  hence  we  do  not  always  find  it  fully  developed  at  the  time 
of  autops}^  Pyaemic  patients  do  not  always  die  with  suppuration  of 
the  joint,  and  I  have  witnessed  reabsorption  in  cases  where  the  patient 
lived  through  the  purulent  infection.  The  treatment  does  not  difi'er 
from  that  above  given  ;  if  the  collection  of  pus  is  excessive,  puncture 
will  relieve  the  pain.  Suppurations  of  the  joint  due  to  injuries,  and 
lacerations  of  the  urethra  by  careless  catheterization,  and  usually 
accompanied  by  chills,  are  of  course  pyeemic,  not  gonorrhoeal.  In 
Berlin  I  treated  a  young  man  who  had  a  rupture  of  the  urethra  caused 
by  bougies,  and  consequently  an  abscess  of  the  left  shoulder,  with 
suppuration  of  the  acromial  joint  of  the  clavicle,  which  induced  sub- 
luxation of  that  bone.  The  patient  recovered  perfectly ;  and,  as 
the  abscess  was  not  large,  it  was  not  opened.  A  j^ear  later  I  saw 
the  young  man  again.  The  abscess  had  become  somewhat  smaller, 
fluctuation  was  still  distinct;  but,  as  it  caused  no  disturbance  of 
function  or  other  difficulty,  and  the  patient  w^as  blooming  and 
healthy,  I  avoided  opening  the  abscess,  and  advise  you  to  do  the 
same  with  cold  abscesses  which  evidently  communicate  with  a  joint, 
as  the  opening  does  little  good  and  may  do  much  harm,  by  pos- 
sibly inducing  acute  inflammation  of  the  joint  and  very  disagree- 
able results. 

3.  Puerperal  inflammations  of  the  joints.  Puerperal  fever  is  a 
term  of  pyaemia  that  may  occur  after  parturition.  Hence,  the  suppu- 
rative inflammations  of  the  joints  occurring  at  that  time  come  under 


344  INFLAMMATION   OF   THE   JOINTS. 

the  above  category  of  pA^semic,  suppurative  synovitis.  But  not  unfre- 
quently,  the  third  or  fourth  week  after  parturition,  there  is  an  acute 
suppurative  inflammation  of  the  knee  and  elbow  joints,  which  has  been 
referred  to  various  causes.  Some  say  it  is  a  simple  form  of  acute 
articular  inflammation  due  to  catching  cold,  to  which  women  are  par- 
ticularly liable  after  confinement,  because  they  perspire  so  much. 
Others  are  of  the  opinion  that  these  late  inflammations  of  the  joints 
are  also  symptoms  of  pyaemia  that  have  been  overlooked  and  are 
isolated,  and  hence  consider  them  as  metastatic.  Let  this  be  as  it 
may,  it  is  at  all  events  certain  that  these  cases  have  nothing  specific. 
They  run  either  an  acute  or  subacute  course,  and,  under  suitable  treat- 
ment, may  be  so  controlled  that  the  joint  will  remain  movable  ;  but 
sometimes  a  more  chronic  course  begins  later  and  terminates  in 
anchylosis.  The  prognosis  is  not  very  bad.  They  rarely  reach  the 
highest  grade  of  acuteness.  The  treatment  is  the  same  as  that 
already  given  for  acute  suppurative  synovitis. 

I  would  also  mention  that  purulent  articular  inflammations  occur 
in  the  pyaemia  of  the  newly-born ;  children  are  even  occasionally  bom 
with  them,  as  has  been  witnessed  by  myself  and  others.  Inflamma- 
tions of  the  joints  may  develop  and  even  run  their  course  during  foetal 
Ufe,  as  is  shown  by  the  cases  where  children  are  born  with  joints  fully 
developed  but  anchylosed. 


APPENDIX  TO  CHAPTERS  I.-XI. 

BETR 0 SPEC T.— GENERAL    REMARKS    ON  ACUTE 
INFLA3niA  TIOK 

Gentlemen  :  Thus  far  I  have  given  you  a  nmnber  of  clinical  sur- 
gical pictures  representing  various  forms  of  acute  inflammation.  We 
have  seen  injuries  and  their  results,  as  well  as  the  acute  surgical  dis- 
eases occurring  without  injurA%  and  have  studied  the  disturbed  physi- 
ological processes,  the  means  of  their  removal,  and  the  process  of  this 
removal.  It  seemed  as  if  this  method  would  be  stimulating  for  you, 
and  that  it  was  permissible,  as  you  were  supposed  to  have  some 
knowledge  of  general  pathology  and  some  starting-point  for  patho- 
logical, phj^siological,  and  histological  investigations.  Still,  it  will 
not  be  superfluous,  at  the  close  of  this  first  ^nd  most  extensive  sec- 
tion of  our  work,  to  give  a  brief  rhume  of  the  present  views  of  in- 
flammation, which  have  been  greatly  advanced  by  recent  labors  of 
Cohnheim,  Samuel,  Arnold,  and  others. 


GENERAL   REMARKS   ON   ACUTE   INFLAMMATIOX.  345 

I  will  begin  by  saying-  that  from  our  ignorance  of  the  participa- 
tion of  nerves  in  inflammation,  we  must  leave  tliera  out  of  the  ques- 
tion. Vessels,  blood,  and  tissue  form  almost  exclusively  the  objects 
of  our  study. 

Dilatation  of  the  blood-vessels  is  an  important  factor  in  inflam- 
mation ;  still,  neither  the  hyperemia  from  hinderance  to  the  current 
of  blood  in  the  veins  (congestive  hyperaemia)  or  dilatation  of  the 
arteries  from  paralysis  of  their  walls  (as  in  the  rabbit's  ear  after 
division  of  the  cervical  sympathetic),  nor  the  sudden  primary  dilata- 
tion from  mechanical  and  chemical  irritations,  necessarily  leads  to 
inflammation.  About  the  latter  form  of  vascular  dilatation  I  have 
something  to  add  to  what  has  already  been  said.  It  is  about  the 
following  symptom  :  You  rub  the  eye,  and  it  becomes  red ;  you  rub 
the  skin,  and  it  becomes  red,  as  it  also  does  if  30U  apply  warm  wa- 
ter ;  you  put  snow  on  the  skin,  and  it  becomes  white,  then  red.  All 
of  these  reddenings  soon  pass  off  if  their  causes  only  acted  a  short 
time  and  were  soon  removed.  The  investigations  luentioned  in  Lec- 
ture V.  referred  to  the  mode  of  origin  of  these  h^^peraemias,  but  they 
are  now  considered  unsatisfactory.  The  symptom  itself  is  completely 
estimated  by  Cohnhehn  ;  still,  even  under  the  action  of  heat,  cold, 
and  chemical  influences,  if  we  suppose  a  direct  momentary  paralysis 
of  the  vascular  walls,  from  what  we  have  thus  far  seen,  it  appears 
strange  that  a  paralyzing  influence  should  extend  from  a  circum- 
scribed pressure  or  tear  to  an  extensive  portion  of  surrounding  vas- 
cular territory,  with  a  sort  of  wave-like  motion.  It  seems  to  me  we 
know  no  more  about  this  "  affluxus  "  to  the  "  stimulus  "  than  we  for- 
merly did.  But  it  is  important,  as  Cohnheim  has  shown  that  where 
inflammations  occur  after  physical  or  chemical  influences,  these  pri- 
mary fluxions  may  have  passed  over  long  before  the  new  hyperaemia 
W'hich  leads  to  and  continues  with  the  inflammation  ;  and  the  pri- 
mary fluxions  may  entirely  fail,  but  a  regular  inflammation  with  its 
hyperaemia  nevertheless  occurs.  Hence  the  fluxion  immediately  fol- 
lowing the  irritation  is  not  an  absolutely  necessary  factor  of  the 
inflammation. 

A  rabbit's  ear  whose  vessels  have  been  paralyzed  and  dilated  by 
section  of  the  sympathetic  does  not  inflame ;  its  tissue  becomes  luore 
tense  from  cedema,  but  nothing  more  ;  there  is  no  further  disturb- 
ance of  nutrition  in  the  vessels  and  tissues. 

Extensive  congestion,  however,  is  more  serious.  It  has  already 
been  stated  in  Lecture  V.  that  slight  increase  of  intravascular  press- 
ure, such  as  occurs  after  moderate  injuries,  quickly  passes  over  and 
has  no  effect  on  the  inflammation.  But  if  the  congestion  be  very 
extensive  and  cannot  be  equalized,  there  is  so  copious  an  exudation 


346  CIRCULATION  IN  INFLAMED  TISSUE. 

of  serum  in  the  tissue  (oedema)  that  it  cannot  be  carried  off  by  the 
lymphatics  ;  sometimes  there  is  free  escape  of  red  blood-corpuscles 
through  the  walls  of  the  capillaries  into  the  tissues  (diapedesis). 
Cohnheim  stated  it  as  probable  that  the  diapedesis  resulted  through 
openings  in  the  capillary  walls.  Arnold  not  only  confirmed  this, 
but  indicated  the  so-called  stigmata  (tlie  small  openings  which  be- 
come visible  between  the  cells  forming  the  capillaries,  after  staining 
with  silver)  as  the  point  of  escape,  and  also  showed  that  blood-serum 
flowed  out  through  these  stigmata.  If  the  hinderance  to  the  circu- 
lation be  of  such  a  nature  that  blood  can  continue  to  flow,  the  only 
results  will  be  oedema  and  diapedesis  ;  if  the  circulation  be  entirely 
arrested,  gangrene  results. 

Coming  at  last  to  hyperasmia  as  it  occurs  in  inflammation,  it  is 
neither  the  immediate  result  of  temporary  inflammation,  nor  of  paral- 
ysis of  the  vaso-motor  nerves,  nor  of  obstruction  to  the  circulation, 
but  of  a  peculiar  alteration  of  the  walls  of  the  vessels,  especially  of 
the  capillaries  and  veins.  What  chemical  or  physical  changes  occur 
at  the  same  time  in  the  walls  of  the  vessels  cannot  be  stated ;  but 
we  conclude  that  the  vessels  in  the  inflamed  part  are  permanently 
dilated,  and  permit  the  free  escape  of  wliite  blood-corpuscles  (not 
only  at  the  stigmata,  but  at  any  point  in  their  walls),  and  that  the 
substance  of  these  vessels  is  softened  and  more  yielding.  Why  this 
is  so,  certainly  cannot  be  determined  in  all  cases;  it  is  considered  as 
a  direct  effect  of  the  cause  of  the  inflammation,  though  it  does  not 
occur  for  some  hours.  The  inflamed  borders  and  areolas  around 
sharplj'-bordered  cuts  or  stabs  are  just  as  diflScult  to  explain  as  the 
primary  fluxions.  We  must  even  involuntaril}'  suppose  that  a  dis- 
turbance can  never  be  accurately  confined  to  the  part  supplied  by  a 
certain  vessel,  but  that  it  must  spread  somewhat,  least  so  in  cuts, 
stabs,  or  rapid  bums,  and  most  so  after  certain  chemical  actions. 
Still,  this  is  no  true  explanation ;  it  is  merely  a  limitation  of  obser- 
vation. 

Let  us  now  consider  the  blood  and  its  circulation  in  inflamed 
tissue.  Primary  fluxion  is  accompanied  by  greatly  increased  ac- 
tivity of  the  movement  of  the  blood,  especially  in  the  arteries, 
which  again  becomes  normal  as  the  primarj^  dilatation  of  the  vessels 
recedes.  In  the  vessels  which  dilate  permanently,  in  the  borders 
and  areola  of  the  inflammation,  the  rapidity  of  the  circulation  grad- 
ually diminishes,  especially  in  the  veins  ;  the  blood  may  move  by 
impulses,  or  occasionally  stop  completely.  This  stasis,  which  is  not 
at  once  accompanied  by  coagulation  of  the  blood,  was  formerly  re- 
garded as  a  necessary  part  of  true  inflammation,  and  had  many  expla- 
nations, which  hardly  interest  us  now,  as  we  know  that  many  inflam- 


GENERAL   REMARKS   OX  ACUTE   INFLAMMATION.  347 

mations  run  their  course  without  stasis,  as  well  as  that  this  stasis 
often  disappears  in  spite  of  progressing  inllamuiation.  If  it  contin- 
ues, the  blood  finally  coagulates  in  the  vessel  (thrombosis),  tlie  results 
of  which  vary  with  local  conditions  and  the  extent;  there  may  be  a 
return  to  the  normal  state  by  collateral  dilatation,  or  gangrene  may 
result.  The  circulation  in  the  inflamed  part  is  at  first  slow  and  ir- 
regular, and  again  becomes  normal.  Meantime  numerous  white 
blood-cells  collect  along  the  walls  of  the  small  veins  and  capillaries ; 
then  they  wander  through  the  walls  of  the  vessels  into  the  tissues, 
whose  interstices  become  filled  (cellular,  or,  if  excessive,  purulent 
infiltration)  ;  and  finally  they  reach  the  surface  (superncial  suppura- 
tion, purulent  catarrh). 

We  have  now  the  complete  picture  of  acute  inflammation  ;  but 
the  process  may  recede  at  the  time  of  dilatation  of  the  vessels  and 
arrest  of  the  white  blood-cells,  and  even  subsequently,  when  cellular 
infiltration  has  advanced  quite  far,  without  leaving  any  change  per- 
ceptible in  the  tissue  that  has  been  infiltrated  or  the  vessels  which 
have  been  dilated.  But  at  a  certain  height  of  the  purulent  infiltra- 
tion the  tissue  disappears  entirely,  and  is  replaced  by  pus  (an  ab- 
scess forms),  or  by  an  interstitial  neoplasia  (granulation  tissue), 
which,  if  it  does  not  die,  becomes  connective  tissue  (cicatrix),  with 
vessels  and  nerves. 

The  question  arises.  What  causes  this  atrophy  of  inflamed  tissue  ? 
Is  it  the  dii'ect  efiect  of  the  cause  of  the  inflammation  or  of  the  cellu- 
lar infiltration  ?  Here  we  come  to  the  third  important  point  in  in- 
flammation, namely,  the  part  taken  by  the  tissue  itself.  If  we  first 
consider  the  inflammations  caused  by  known  chemical  or  physical 
causes,  it  is  evident  they  cannot  act  on  the  vessels  and  blood  with- 
out at  the  same  time  afi"ecting  the  tissue.  Samuel  starts  from  the 
inflammation  induced  by  chemical  means,  and  explains  it  as  a  result- 
ant of  the  union  of  the  cause  of  the  inflammation  with  the  tissue, 
the  walls  of  the  blood-vessels  and  the  blood.  The  wandering  of  the 
blood-cells,  their  infiltration  in  the  tissue,  and  the  accompanying 
changes,  he  regards  as  secondary  processes.  If  the  action  of  concen- 
trated sulphuric  acid  on  the  tissue  causes  such  a  metamorphosis  that 
circulation  of  blood  and  other  fluids  is  no  longer  possible,  the  tissue 
is  directly  killed ;  but  the  most  essential  tiling  in  the  inflammation 
is  the  change  of  tissue  afi'ected  by  dilute  sulphuric  acid  (whether  at 
the  borders  of  a  part  cauterized  by  strong  acid  or  where  only  dilute 
acid  was  used),  where  circulation  still  continues.  According  to  this, 
if  I  have  rightly  understood  SamuePs  explanation,  the  disturbance 
in  the  inflamed  tissue  would  vary  in  diff'erent  cases,  according  as  the 
active  cause  was  an  acid,  an  alkali,  ethereal  oil  (as  oil  of  turpen- 


348  DILATATIOX   OF   VSINS   AND   CAPILLARIES. 

tine),  or  an  acrid  oil  (as  croton-oil),  etc.  The  condition  of  the  in- 
flamed tissue  would  differ  also  with  action  of  extreme  cold,  great 
heat,  crushing,  after  steam  on  exposed  surfaces  or  serous  membranes, 
etc.  So  we  should  have  to  renounce  entirely  a  uniform  representation 
of  the  chemical  processes  in  the  inflamed  tissue.  I  do  not  know  if 
this  view  will  ever  prove  popular  in  this  form.  Hitherto  we  have 
classed  these  changes  of  tissue  at  the  seat  of  inflammation  all  to- 
gether; just  as  by  concussion  of  the  brain  we  should  mean  not  only 
the  moment  of  concussion,  but  also  its  immediate  efi'ect  on  the  brain 
and  its  functions.  If  the  concussion  be  followed  by  inflammation  of 
the  brain,  the  changes  caused  by  the  concussion  may  influence  the 
nature  and  extent  of  the  inflammation;  but  we  do  not  say  that  a 
brain  suffering  from  concussion  is  already  inflamed.  The  same  is 
true  of  contusions :  if  the  normal  function  of  a  tissue  has  been  af- 
fected by  a  concussion,  but  its  function  not  entirely  destroyed,  the 
circulation  will  differ  from  normal,  and  this  modification  we  call  in- 
flammation, but  do  not  so  term  the  immediate  result  of  the  contu- 
sion. The  processes  in  the  tissues,  after  chemical,  physical,  or  me- 
chanical injuries,  are  essentially  similar,  difl'ering  only  in  extent  and 
intensitv  ;  they  are  what  we  term  inflammation,  and  in  it  the  tissue 
itself  plays  an  important  part,  which  varies  with  the  way  the  cause 
has  directly  affected  the  tissue. 

A  constant  perceptible  result  of  acute  inflammation  is  dilatation 
of  the  veins  and  capillaries,  with  escape  of  white  blood-cells  and  cer- 
tain disturbances  of  the  physiological  functions  of  the  affected  tissue. 
For  all  this  to  occur,  one  function  of  the  vessels,  especially  that  of 
the  cellular  elements  of  keeping  the  blood  in  the  channels  formed  by 
them,  must  be  disturbed  ;  but  would  such  a  disturbance  be  confined 
to  the  walls  of  the  ve'i-sels,  and  not  extend  to  the  adjacent  tissue  ? 
This  is  not  very  probable.  The  granular  cloudiness  occurring  in  in- 
flamed muscle,  the  indistinctness  of  the  filaments  in  inflamed  con- 
nective tissue,  the  granular  disintegration  in  inflamed  nerve-filaments, 
the  rapid  loss  of  color  of  red  blood-cells  in  acutely  inflamed  tissue, 
all  indicate  that  certain  constant  changes  go  on  in  the  tissue  also, 
which  usually  lead  to  gradual  solution  or  death  of  the  tissues,  unless 
gangrene  occurs  from  rapid  increase  of  the  process.  I  acknowledge 
there  is  no  proof  that  these  changes  begin  simultaneously  with  those 
in  the  vessels,  and  that  they  may  be  regarded  as  an  immediate  re- 
sult of  the  latter  ;  for  if  we  find  these  alterations  of  tissue  withr^ut 
dilatation  of  the  vessels  and  cell-emigration,  or  if  we  artificially  cause 
this  state  by  obstructing  the  circulation  to  the  injured  part  [Samuel), 
tliere  may  be  a  doubt  as  to  whether  it  is  to  be  termed  inflammation 
in  the  ordinary  sense   ( C jJinhehn).      But,  on  the  other  hand,  at- 


GENERAL   REMARKS   ON   ACUTE   INFLAMMATION.  049 

tempts  have  been  made  to  distinguish  the  changed  condition  of  the 
vessels  which  permits  the  extensive  escajoe  of  white  blood-cells  from 
inflammation.  When  studying  chronic  inflammation,  we  shall  see 
that  all  of  these  factors  can  occur  separately,  and  that  it  is  .only  their 
combination  which  forms  what  we  call  inflammation. 

Vlrchoio  located  the  inflammatory  disturbances  chiefly  in  the 
tissue  ;  he  was  led  to  this  partly  by  the  microscopic  changes  just 
mentioned,  partly  from  the  observation  that  on  irritation  young 
cells  appeared  even  in  non-vascular  tissues,  like  the  cornea  and  car- 
tilage, just  as  they  do  in  vascular  tissues.  These  latter  observa- 
tions, which  were  made  at  a  time  when  the  emigration  of  white 
blood-cells  was  not  understood,  can  now  be  differently  interpreted 
(Lecture  VI.).  We  doubt  now  just  as  little  as  formerly  that  carti- 
lage-cells and  some  others,  as  certain  endothelia  of  serous  membranes 
[Hmdjfeisch,  iLundr at),  young  epithelial  cells  (Hernak,  Suld,  liind- 
fleisch),  etc.,  on  being  irritated  in  a  certain  v,'ay,  will  form  new  pro- 
toplasm and  new  cells  in  themselves,  will  divide  uj?,  and  may  thus 
lead  to  formation  of  new  tissue.  It  is  stiil  doubtful  whether  all 
cells  thus  formed  have  independent  movements,  like  pus-cells  ;  but 
very  few  observers  now  believe  that  developed  connective  tissue, 
corneal  or  bone  corpuscles,  acquire  this  peculiarity ;  it  is  pretty  gen- 
erally recognized  that  formation  of  pus  does  not  result  from  local 
proliferation  of  fixed  connective-tissue  cells,  according  to  VircJioio''s 
theory.  Manv  regard  it  as  still  undecided  how  much  the  wandering 
cells  have  to  do  with  inflammatory  new  formations  ;  from  my  obser- 
vations I  can  hardly  doubt  that  the  tissue  which  causes  healing  by 
first  intention,  as  well  as  granulation  tissue,  may  proceed  from  wan- 
dering cells,  although  another  mode  is  possible  (by  ofi'shoots,  direct 
outgrowth  from  the  tissue,  Lecture  VI.).  The  transformation  of 
wandering  cells  into  connective  tissue  seems  to  me  quite  plausible, 
for,  according  to  my  investigations,  they  probably  originated  from 
connective-tissue  cells,  namely,  from  the  stellate  cells,  filaments  of 
lymphatic  glands.  Of  late,  attempts  have  been  made  to  explain  why 
the  above-mentioned  tissue-cells,  such  as  cartilage-cells,  after  certain 
irritations,  begin  to  enlarge,  divide,  and  finally  to  produce  new  tis- 
sue, by  the  hypothesis  that  every  protoplasm,  supplied  with  proper 
nourishment,  would  grow  and  divide  up  if  not  hindered  by  the  press- 
ure of  the  tissue  in  which  it  develops  ;  the  partial  escape  of  the  nu- 
cleus, as  from  injury  or  increased  distensibility  of  the  tissue,  the 
nutritive  conditions  being  otherwise  good,  is  said  to  be  enough  to 
start  the  remains  of  the  cell  into  growth.  This  hypothesis,  which 
was  advanced  by  Thiersch  for  another  object,  and  which  has  been 
warmly  taken  up  and  generalized  by  Samuel,  seems  very  ingenious, 


350  FORMATIOX   OF   FIBRINE. 

and  I  think  it  may  prove  tlie  fruitful  basis  of  future  observations. 
But  tissue-development  is  dependent  on  other  important  factors  be- 
sides the  conditions  of  nutrition  and  pressure,  as  on  inherited  pecu- 
liarities of  the  protoplasm  ;  and  the  above  hypothesis  does  not  suit 
all  cases — for  instance,  the  endogenous  cell-development  of  the  endo- 
thelium after  inflammatory  irritation  of  the  peritoneum. 

It  is  not  known  whether  there  is  a  primaiy  disturbance  of  nutri- 
tion in  the  tissues  themselves,  independent  of  the  blood-vessels  and 
their  functions,  that  induces  the  specific  inflammatory  alteration  in 
the  vessels.  The  deposit  of  urates  in  the  tissue  of  certain  parts  of 
the  body  in  arthritis  is  usually  regarded  as  of  this  nature ;  but  the 
deposit  requires  participation  of  the  vessels,  and  so  they  and  the 
tissues  are  simultaneously  aifected.  An  experiment  of  Cohnheiin 
shows  that  continued  exclusion  of  blood  from  a  blood-vessel  may  so 
afi'ect  its  walls  that  when  the  blood  again  enters  there  will  be  a  free 
emigration  of  white  blood-cells.  It  was  mentioned  above  that  con- 
tinued stasis  of  the  blood  did  not  have  this  efi"ect  on  the  walls  of  the 
vessel  where  it  was  stagnated ;  but  from  clinical  grounds  it  is  prob- 
able that  the  pressure  of  extensively  and  rapidly  distended  vessels 
on  the  parts  around  has  something  to  do  with  their  inflammation. 

It  is  very  probable  that  inflammations  may  be  induced  not  only 
by  chemical,  physical,  and  mechanical  causes,  which  act  from  with- 
out directly  on  certain  parts  of  the  body,  but  also  by  primary  disturb- 
ances of  nutrition  in  the  tissues  and  of  the  circulation,  which  develop 
in  the  body  without  perceptible  cause. 

I  nuist  not  forget  to  mention  one  symptom  which  formerly  played 
a  great  role  in  inflammation,  but  is  now  hardly  mentioned  ;  that  is, 
the.  fonnatlon  offlbrine  in  some  inflammations.  This  occurs  chiefly, 
indeed  almost  exclusively,  in  inflammation  of  the  connective  tissue, 
and  sometimes  on  the  surface  of  serous  sacs,  of  fresh  and  granulat- 
ing wounds,  and  of  mucous  membranes  (of  pharynx,  larynx,  and 
bronchi)  ;  in  other  cases  the  nutrient  fluid  in  the  connective  tissue 
assumes  a  fibrinous  rigidity.  It  has  been  already  mentioned  that 
the  formation  of  fibrine  is  not  from  an  excess  of  fibrine  in  the  blood, 
but  from  chemical  alteration  in  the  inflamed  parts.  Fibrine  forms 
in  the  inflamed  tissue,  but  is  not  a  constant  result  of  inflammation. 
The  great  difference  of  the  other  symptoms  occurring  with  fibrinous 
inflammations  is  remarkable.  Wiiile  rapid  formation  of  a  moderate 
amount  of  fibrine  favors  healing  by  the  first  intention  and  partial 
adhesion  of  the  surfaces  of  serous  membranes,  when  often  scarcely  a 
trace  of  inflammation  or  fever  is  perceptible,  in  other  cases,  from 
some  enigmatical  cause,  a  very  moderate  fibrinous  deposit  in  the 
tissues  (as  fibrinous  deposit  on  the  mucous  membrane  of  the  throat. 


GENERAL   REMARKS   ON  ACUTE    INFLAMMATION.  351 

diphtheria)  causes  death.  It  is  very  evident  that  fibrinous  harden- 
ing of  the  tissue  fluids  is  one  of  the  severest  alterations  of  their  nu- 
trition ;  and,  as  experience  shows,  it  often  ends  in  necrosis.  Still, 
the  severe  general  symptoms  and  extensive  inflammatory  redness  in 
these  processes  cannot  be  due  simply  to  the  formation  of  fibrine,  but 
seem  referable  to  absorption  of  the  products  of  decomposition  in  the 
diseased  tissue,  which  has  a  very  rajiid  poisonous  action.  In  the 
acute  inflammations  with  formation  of  fibrine  there  seems  to  be  a 
scale  of  malignanc}''  similar  to  those  without  such  formation,  so  that 
this  would  seem  to  be  rather  an  accident  due  to  the  variety  of  the 
tissue  and  its  locality ;  and  while  its  significance  is  very  important, 
it  is  not  essential  to  the  inflammation,  nor  does  it  materially  chano-e 
the  course. 

The  serous  transudation  also,  which  accompanies  acute  intlam- 
mations,  deserves  a  short  notice.  In  many  cases  it  certainly  is  the 
result  of  change  of  pressure  in  the  vessels  at  the  seat  of  inflamma- 
tion ;  but  it  is  just  as  much  due  to  impaired  function  of  the  walls 
of  the  vessels  and  of  the  tissue;  it  is  often  a  prominent  symptom  in 
inflammations  of  the  connective  tissue,  especially  of  serous  mem- 
branes. The  walls  of  the  vessels  cannot  hold  the  serum  of  the 
blood;  the  tissue  does  not  prepare  it  ;  veins  and  lymphatics  do  not 
carry  it  away,  especially  if  they  are  covered  and  stopped  up  by 
fibrine  (in  inflammation  of  serous  surfaces  on  which  tlio  lymphatics 
open).  The  serum  in  acutely  inflamed  tissue  is  essentially  difi'erent 
from  that  which,  without  inflammation,  causes  dropsy,  for  it  not 
only  contains  wandering  cells  and  disintegrated  red  blood-cells,  but 
also  the  soluble  products  of  the  inflammation.  The  removal  of  this 
fluid  by  the  veins  and  lymphatics  releases  the  tissues  from  a  consid- 
erable pressure  and  carries  ofi"  the  injurious  products,  it  is  true ;  but 
part  of  it  at  least  is  carried  into  the  blood,  and  probably  causes  the 
inflammatory  fever.     This  has  already  been  fully  treated  of. 

Now  we  might  speak  of  the  causes  why  circumscribed  and  often 
purely  mechanical  irritations,  acting  on  small  portions  of  the  body, 
occasionally  excite  such  intense  spreading  inflammations,  and  of  the 
way  these  spread.  But  I  will  ncjt  now  trouble  you  further  with  this 
subject.  I  have  already  said  something  about  it  in  Lecture  XXI., 
and  shall  hereafter  have  occasion  to  say  more. 

Pathological  anatomists  have  paid  too  little  attention  to  these 
questions  ;  surgeons  see  their  importance  too  often,  and  seek  in 
vain  for  a  means  to  arrest  these  spreading  inflammations.  In  the 
clinic  there  will  be  many  opportunities  to  call  your  attention  to 
these  important  points. 

It  is  in  the  nature  of  our  times  to  undervalue  the  significance 


352 


VALUE   OF   THEORETICAL   REFLECTIONS. 


and  practical  value  of  these  so-called  theoretical  reflections  with 
which  I  have  perhaps  fatigued  some  of  you.  But  hereafter,  when 
you  have  been  in  practice  for  some  years,  you  will  hardly  be  able  to 
read  and  understand  a  medical  work  if,  during  your  student-life,  you 
have  not  acquired  a  basis  on  which  to  build.  After  some  years  of 
practice  some  of  you,  who  are  now  sated  with  lectures,  will  long- 
to  hear  a  continuous  scientific  exposition  of  imjjortant  morbid  pro- 


cesses. 


CHAPTER  XII. 
GANGRENE 


LECTURE  XXIII. 

Dry,  Moist  Gangrene. — Immediate  Causes. — Process  of  Detachment. — Varieties  of  Gan- 
grene according  to  tlie  Remote  Causes.— 1.  Loss  of  Vitality  of  the  Tissue  from 
Mechanical  or  Chemical  Causes. — 2.  Complete  Arrest  of  the  Afflux  and  Efflux  of 
Blood. — Incarceration. — Continued  Pressure. — Decubitus. — Great  Tension  of  the 
Tissue. — 3.  Complete  Arrest  of  the  Supply  of  Arterial  Blood. — Gangrena  Spon- 
tanea.— Gangrena  Senilis. — Ergotism. — i.  Noma. — Gangrene  in  Various  Blood- 
Diseases. — Treatment. 

^YE  Imve  already  spoken  frequently  of  gangrene  and  mortification. 
You  know  in  general  what  tliey  mean,  and  have  already  encountered 
a  series  of  cases  where  there  was  local  death  of  a  part ;  but  there  are 
many  other  circumstances,  with  which  you  are  not  yet  acquainted, 
which  favor  gangrene  ;  all  of  which  we  shall  include  in  this  chapter. 

You  already  know  tlie  word  (jangrene  to  be  perfectly  synonymous 
with  mortification.  Originally  it  was  only  used  to  express  the  stage 
where  the  dying  part  was  still  hot  and  painful ;  that  is,  not  completely 
dead.  This  was  called  "  hot  mortification,"  while  the  moist  "  cold 
mortification  "  was  called  by  the  old  authors  sphacelus.  The  word 
mummification  is  also  employed  for  dry  gangrene.  From  the  moment 
the  circulation  ceases,  moist  gangrene  is  perfectly  analogous  to  ordi- 
nary putrefaction.  Although  it  cannot  always  be  certainly  stated  wh}' 
dry  gangrene  occurs  in  one  case  and  moist  in  another,  we  say  gener- 
ally that  when  the  circulation  ceases  suddenl}^,  especially  if  the  parts 
liave  been  previously  inflamed  or  oedematous,  moist  gangrene  occurs. 
Dry  gangrene — mummification  or  shrinking  of  the  parts — is  more  fre- 
quently due  to  gradual  death,  where  the  circulation  has  continued 
I'eebly  in  the  deeper  parts,  and  the  serum  has  been  carried  off  from 
the  gradually-dying  parts  by  the  lymphatic  vessels  and  veins.  Rapid 
evaporation  of  the  fluid  also  induces  gradual  dryness.  It  is  certainlv 
24 


354  CAUSES  OF  GANGRENE. 

true  that  even  in  moist  gangrene  a  superficial  dryness  of  the  skin  may 
occasionally  be  obtained  by  removing  the  hard  laj^er  of  the  epidermis, 
which  readily  peels  off  from  the  decomposing  limb ;  we  may  also 
greatly  favor  tlie  drying  by  applications  of  substances  having  a  strong 
affinity  for  water,  such  as  alcohol,  solutions  of  corrosive  sublimate, 
sulphuric  acid,  etc. ;  but  we  cannot  obtain  so  complete  a  mummifica- 
tion as  sometimes  occurs  spontaneously.  Hence,  dry  gangrene  is  not 
a  simple  putrefaction,  but  a  rather  comphcated  process,  which  gradu- 
ally leads  to  arrest  of  the  circulation. 

The  immediate  cause  of  death  of  individual  parts  of  the  body  is 
always  the  complete  cessation  of  the  supply  of  nutriment  consequent 
on  arrest  of  circulation  in  the  capillaries ;  under  some  circumstances 
the  chief  arteries  or  veins  of  an  extremity  may  be  locally  obstructed, 
and,  nevertheless,  the  blood  finds  its  way  by  neighboring  branches 
into  their  lower  or  upper  parts.  Hence,  obstruction  of  an  artery  can 
only  be  the  immediate  cause  of  gangrene  when  collateral  circulation 
is  impossible.  This  may  be  due  partly  to  anatomical  conditions,  partly 
to  great  rigidity  of  the  walls  of  small  arteries,  partly  to  very  exten- 
sive destruction  of  the  walls  of  the  artery,  as  when  the  femoral  is 
obstructed  from  the  bend  of  the  leg  to  the  foot,  the  nutrition  only 
ceases  when  the  capillary  circulation  is  rendered  impossible  by  these 
circumstances.  But  it  is  not  always  necessary  that  cessation  of  cir- 
culation in  a  small  capillary  district,  or  in  the  parts  supplied  by  one 
small  artery,  should  cause  actual  decomposition ;  under  such  circum- 
stances the  distmbance  of  nutrition  may  assume  a  milder  form,  espe- 
cially when  this  limited  disturbance  of  circulation  comes  on  slowly 
and  gradually.  In  this  case  there  is  molecular  disintegration  of  tissue, 
which  shrinks  and  dries  to  a  yellow  cheesy  mass,  in  short,  there  is  a 
series  of  metamorjDhoses  w'hich  in  the  cadaver  appear  as  dry,  yellow 
infarctions  ;  this  is  essentially  merely  a  sort  of  dry  gangrene  limited 
to  a  small  spot.  If  this  disturbance  of  nutrition  and  molecular  disin- 
tegration of  tissue  take  place  on  a  surface,  we  call  it  ulceration  y  tlie 
whole  series  of  so-called  atonic  ulcers,  to  which  we  shall  hereafter 
return,  are  mostly  due  to  such  quantitative  disturbances  of  nutrition. 
Hence,  intimate  as  is  the  connection  between  the  causes  of  dry  gan- 
grene and  ulceration,  still,  the  various  forms  of  gangrene  are  well 
marked  and  peculiar,  as  you  w'ill  see  from  what  follows,  as  there  is 
generally  not  only  molecular  disintegration  of  tissue,  but  death  of 
whole  shreds  of  tissue,  or  even  of  an  entire  limb.  A  priori^  it  is  cer- 
tainly supposable  that  complete  closure  of  all  the  veins  returning 
blood  from  a  limb,  should  induce  complete  stasis  in  the  capillaries ; 
but  in  practice  this  is  very  unlikely  to  occur,  for  the  veins  are  so  very 
numerous,  and  in  almost  all  parts  of  the  body  there  are  two  ways  for 


GANGRENE.  355 

the  return  of  blood,  viz.,  the  deep  and  subcutaneous  veins,  which 
communicate  freely ;  if  one  way  be  closed,  the  other  will  be  at  least 
partly  open.  When  dry  gangrene  occurs  in  the  skin  and  deeper  soft 
parts,  they  usually  assume  a  grayish-black,  then  a  coal-black  hue.  In 
cases  where  the  parts  were  previously  inflamed,  the  skin  appears  at 
first  dark  violet,  then  whitish  yellow,  it  only  becomes  brownish  or 
grayish  black  in  case  of  partial  drying;  dead  tendons  and  fasciae 
change  their  color  little.  When,  from  disturbance  of  the  circulation,  a 
considerable  portion  of  tissue  ceases  to  be  nourished,  the  border  be- 
tween dead  and  living  regularly  becomes  more  distinctly  marked ; 
around  the  dead  skin  there  forms  a  bright-red  line,  the  so-called  line 
of  demarcation.  This  redness  is  caused  by  distention  of  the  capillary 
vessels,  which  is  partly  due  to  collateral  circulation  in  them,  partly  to 
fluxion  induced  by  the  decomposing  fluids,  and  exactly  resembles  the 
redness  around  the  edges  of  a  wound  with  loss  of  substance,  especially 
of  a  contused  wound,  as  we  have  already  explained.  Along  wdth  these 
changes  in  the  vessels  there  is  an  active  cell-infiltration  in  the  line 
of  demarcation,  by  which  the  tissue,  whatever  its  nature  may  be,  is 
partly  softened  and  dissolved.  All  over  the  borders  of  the  living 
tissue  young  cells  in  the  form  of  pus  appear  in  place  of  the  firm  tissue, 
and  then  the  coherence  of  the  parts  ceases.  The  dead  becomes  de- 
tached from  the  living,  and  on  the  borders  of  the  latter  there  is  a  layer 
of  tissue  changed  by  infiltration  of  plastic  matter  and  ectasia  of  the 
vessels,  granulations.  To  express  this  simply  in  surgical  language  we 
say :  The  dead  tissue  must  be  thrown  ofi"  from  the  living  by  free  sup- 
puration, and  this  detachment  of  the  dead  tissue  is  followed  by  active 
granulations  which  cicatrize  in  the  usual  manner.  Tliis  process  repeats 
itself  in  all  tissues,  in  all  forms  of  gangrene,  sometimes  quicker,  some- 
times more  slowly,  in  exactly  the  same  way,  even  in  bones,  as  you 
know  from  the  necrosis  of  the  ends  of  the  bone  in  open  fractures.  But 
we  shall  not  here  treat  of  gangrene  of  bones,  as  it  is  so  intimately 
connected  with  their  other  chronic  diseases  that  we  shall  have  to  speak 
of  it  when  treating  of  them.  The  time  required  for  the  detachment 
of  the  dead  tissue  may  vary  greatly.  It  dej^ends :  1.  On  the  size  of 
the  dead  portion ;  2.  On  the  vascularity  and  consistence  of  the  tissue  ; 
3.  On  the  strength  and  vitality  of  the  patient. 

As  gangrene  is  usually  the  result  of  other  diseases,  it  is  not  always 
easy  to  correctly  group  the  symptoms  which  are  to  be  referred  to  it. 
If  the  line  of  demarcation  has  formed,  and  the  process  of  detachment 
is  going  on,  an  efl"ect  on  the  general  health  is  apparent  when  the 
gangrene  affects  large  extremities.  Then  there  is  a  general  marasmus, 
a  gradual  loss  of  strength,  depression  of  the  bodily  temperature,  small 
pulse,  dry  tongue,  a  half-soporose  state  in  which  the  patient  grows 


356  DECUBITUS. 

weaker  and  weaker,  and  finally  dies,  -without  our  bemg  able  to  dis- 
cover in  the  cadaver  any  particular  cause  of  death,  although  in  other 
cases  putrid  metastatic  abscesses  are  found  in  the  lungs.  These  cases 
are  one  form  of  chronic  septicaemia ;  I  have  no  doubt  that  the  repeated 
absorption  of  putrid  matters,  during  the  development  of  gangrene,  by 
the  blood  and  lymphatic  circulation  which  partly  continues,  may  be  the 
cause  of  death.  I  propose  to  return  to  this  question  in  the  next 
section. 

After  these  general  remarks,  we  must  study  more  carefully  the 
different  varieties  of  gangrene,  according  to  their  remote  and  proxi- 
mate causes,  and  their  practical  importance : 

1.  Complete  loss  of  vitality  of  the  tissue  tlu'ough  mechanical  or 
chemical  action,  such  as  crushing,  contusing,  great  heat  or  cold,  caus- 
tic acids  and  alkalies,  continued  contact  with  ammoniacal  urine,  with 
cai'bunculous  poison,  poisons  from  certain  serpents,  putrid  matters 
that  act  as  ferments,  etc.,  come  under  this  head.  We  have  already 
spoken  of  some  of  these  varieties ;  we  shall  shortly  come  to  others  of 
them. 

2.  Complete  arrest  of  the  circulation,  by  circular  compression  or 
other  mechanical  cause,  is  in  many  cases  the  cause  of  capillary  stasis 
and  gangrene.  For  instance,  if  you  surround  a  limb  firmly  with  a 
bandage,  you  will  have,  first,  venous  congestion,  then  oedema,  and 
finally,  gangrene.  Let  us  take  a  practical  example :  if  the  prepuce 
be  too  small  and  be  forcibly  drawn  back  over  the  glans  so  as  to 
cause  a  paraphimosis,  the  compressed  glans,  or  in  this  case  more 
frequently  the  compressing  ring,  becomes  gangrenous.  The  mortifi- 
cation of  strangulated  hernia  depends  on  the  same  cause. 

Continued  pressure  also,  by  arresting  the  afflux  and  efflux  of  blood, 
may  lead  to  gangrene,  especially  in  persons  in  whom  the  heart's  action 
is  weakened  by  long  disease,  or  who  by  general  sejitic  intoxication 
are  already  disposed  to  gangrene. 

JJecubitus,  the  so-called  bed-sore,  is  such  a  gangrene  caused  by 
continued  pressure,  but  all  sorts  of  bed-sores  are  not  gangrenous  from 
the  first,  for  in  some  cases  they  are  rather  to  be  comj^ared  to 
a  gradual  maceration  of  the  epidermis  and  cutis,  as  a  result  of  con- 
tinually lying  in  a  bed  wet  with  sweat,  urine,  and  other  liquids.  De- 
cubitus is  particularly  frequent  over  the  sacrum,  and  may  there  attain 
a  fearful  size,  all  the  soft  parts  becoming  gangrenous  down  to  the 
bone ;  it  may  also  occur  over  the  heel,  the  trochanters  of  the  femur, 
head  of  the  fibula,  scapula,  or  spinous  processes  of  the  vertebra,  ac- 
cording to  the  position  of  the  patient.  The  same  thing  may  be  caused 
by  badly-applied  dressings.  This  disease  is  the  more  impleasant,  as 
it  usually  comes  during  other  exhausting  affections.     Although  no 


GANGRENE.  357 

iisease  in  wliich  the  patient  is  condemned  to  long-,  absolute  quiet,  is 
entirely  exempt  from  the  disagreeable  accompaniment  of  a  decubitus, 
still  some  peculiarly  dispose  to  it,  chief  among  which  is  typhus ;  iu 
patients  with  septicaemia,  decubitus  occurs  very  early,  often  even  after 
three  to  five  days  of  quiet ;  it  usually  bcghis  with  a  very  circumscribed 
congestion  of  the  skin  over  the  sacrum,  while,  with  proper  care,  con- 
sumptive patients  keep  their  beds  for  months  or  years,  without  having 
bed-sores. 

This  disease  is  particularly  troublesome  for  the  patient,  because, 
especially  in  chronic  maladies,  it  may  be  accompanied  by  great  pain ; 
in  acute  cases  of  typhus  and  septicajmia,  on  the  contrary,  the  patients 
sometimes  do  not  feel  it  at  all  when  they  have  a  very  large  bed-sore. 
This  form  of  gangrene  is  particularly  dangerous  when  the  exciting 
causes  cannot  be  entirely  removed,  and  it  becomes  progressive ;  the 
prognosis  is  worse  the  more  exhausted  the  patient ;  not  unfi-equently 
bed-sore  is  the  cause  of  death,  as  it  continues  to  enlarge  in  spite  of 
all  treatment,  or  it  may  be  the  origin  of  a  fatal  pyaemia. 

Too  great  tension  of  the  tissue,  causing  great  distention  of  the 
vessels,  and  compressing  some  of  them,  induces,  on  the  one  hand,  a 
diminished  amount  of  blood,  while  the  pathological  requirements  of 
nutriment  are  increased ;  on  the  other,  a  coagulation  of  blood  in  the 
capillaries  from  the  increased  friction.  This  is  the  cause  of  gangrene 
occurring  in  inflammation,  and  which  we  have  already  mentioned 
when  speaking  of  phlegmon,  but  it  must  not  be  said  that  every  stasis 
of  the  blood  in  the  capillaries  that  may  occasionally  occur  in  inflam- 
mation is  to  be  referred  to  great  tension  of  the  tissues,  as  there  are 
also  other  causes.  It  would  lead  me  too  far  to  enter  on  theories, 
especially  as  you  have  already  heard  them  in  the  course  on  general 
pathology.  Moreover,  we  shall  return  to  this  when  treating  of  throm- 
bosis of  the  veins. 

3.  Complete  arrest  of  the  supply  of  arterial  blood,  which  is  particu- 
larly due  to  diseases  of  the  heart  and  arteries,  must  also  sometimes 
lead  to  gangrene ;  in  this  class  belong  those  cases  of  gangrene 
called  gangrcena  spontanea,  or  oftener  gangrcena  senilis,  from  its 
more  frequent  occv;rrence  in  old  persons ;  this  may  come  in  various 
ways  and  forms.  The  causes  may  vary  thus:  The  coagulation  of 
blood  may  begin  in  the  capillaries  (marasmic  thrombosis  as  a  result 
of  debility  of  the  heart,  or  insufficient  conduction  through  the  smaller 
arteries),  or  as  an  independent  thrombus  of  the  artery,  or,  lastly,  a 
thrombus  from  embolism ;  excessive,  continued  ana3mia  also,  with 
great  consecutive  contraction  of  the  arteries  and  debility  of  the  heart, 
and,  lastly,  continued  spasmodic  contraction  of  the  arteries,  may  in- 
duce gangrene.     Gangrsena  senilis  proper  is  a  disease  originally  oo> 


358  GANGRzENA  SENILIS. 

curring  in  the  toes,  rarely  in  the  fingers,  as  I  once  saw.  There  are 
two  chief  forms :  in  one  of  them  a  brown  spot  forms  on  one  toe ;  it 
eoon  becomes  black,  and  gradually  spreads  till  the  whole  toe  becomes 
completely  dry.  In  favorable  cases  a  line  of  demarcation  forms  at 
the  phalango-metatarsal  articulation,  the  toe  falls  off,  and  the  wound 
cicatrizes.  But  the  mummification  may  go  higher  and  limit  itself  in 
the  middle  of  the  foot,  above  the  malleoli,  in  the  middle  of  the  leg, 
or  just  below  the  knee.  In  another  series  of  cases,  the  disease  be- 
gins with  symptoms  of  inflammation,  oedematous  swelling  of  the  toes, 
very  great  pain,  and  dark,  bluish-red  color,  which  subsequently  be- 
comes black ;  there  are  stages  of  the  disease  where,  by  the  bluish-red, 
mottled  appearance  of  the  skin,  we  may  see  that  in  one  place  the  cir- 
culation is  carried  on  with  the  greatest  difficulty,  Avhile  elsewhere  it 
has  already  ceased ;  this  struggle  between  life  and  death  the  French 
have  not  inaptly  compared  to  death  by  asphyxia,  and  termed  asjyhyxia 
locale.  In  tliis  form  of  moist,  hot  gangrene,  the  disease  usually  attacks 
several  toes  at  once,  and  extends  to  the  foot,  till  in  the  course  of  a 
few  weeks  the  entire  foot,  perhaps  also  the  leg,  becomes  gangrenous; 
at  the  same  time  decomposition  soon  begins  in  the  oedematous  sub- 
cutaneous cellular  tissue,  and  the  danger  of  absorption  of  putrid  mat- 
ter through  the  lymphatic  vessels  is  much  greater  than  in  the  process 
of  mummification.  The  seat  of  the  disease  of  the  arteries  that  leads  to 
spontaneous  gangrene  varies ;  in  acute  (marasmic)  gangrw.na  senilis, 
tlie  pi-imary  coagulation  due  to  feeble  circulation  occurs  in  the  capil- 
laries and  thence  extends  backward  to  the  arteries.  The  feebleness 
of  the  arterial  circulation  may  be  due  to  various  causes :  1.  To  di- 
minished energy  of  the  heart's  action ;  2.  To  thickening  of  the  walls 
of  the  arteries  and  contraction  of  their  calibre ;  3.  To  degeneration 
of  the  muscular  coat  of  the  smaller  arteries.  In  some  cases  all  of 
these  causes  unite,  for,  in  old  persons  -with  feeble  heart-action,  diseases 
of  the  arteries  are  the  most  frequent ;  besides,  affections  of  the  heart 
and  arteries  usually  have  a  common  constitutional  cause.  This  is  not 
the  place  to  discuss  extensively  how  far  rigidity  and  atheroma  of  the 
coats  of  the  artery  are  to  be  referred  to  inflammation,  or  to  be  re- 
garded as  a  peculiar  disease ;  nor  can  I  permit  myself  to  discuss 
further  the  distinctions  of  the  finer  histological  points,  of  which  we 
shall  have  something  to  sa}'-  when  treating  of  aneurisms,  but  will 
simply  mention  that  in  old  persons  the  coats  of  the  arteries  are  often 
thickened,  and  deposits  of  chalk  form  in  them  to  such  an  Extent  that 
the  whole  ai'terj'-  is  calcified  and  the  calibre  considerably  diminiuished 
by  the  thickening  of  the  walls,  and  the  inner  surface  becomes  rough, 
so  as  to  dispose  to  the  fixation  of  blood-clots.  The  original  qualities 
of  the  arteries  are  thus  lost  to  such  an  extent  that  \h.ey  are  neithei 


GANGRENE.  359 

elastic  nor  contractile,  and  bence,  partly  from  the  diminished  calibre, 
partly  from  the  lack  of  contractility,  the  onward  movement  of  the 
blood,  already  moved  less  forcibly  on  account  of  the  feeble  action  of 
the  heart,  is  very  much  impeded,  so  that  it  is  easy  to  understand  how 
coagulation  occurs  in  such  cases,  especially  in  parts  distant  from  the 
heart. 

While  the  cases  just  described  are  with  some  justice  termed  senile 
gangrene,  and  their  connection  with  arterial  diseases  has  been  gen- 
erally recognized  since  the  time  of  Dupuytren^  there  is  another  form 
of  spontaneous  gangrene,  which  occurs  in  old  persons,  but  is  distin- 
guished from  the  above,  because  a  large  portion  of  an  extremity,  as 
of  the  leg  as  high  as  the  calf  or  the  knee,  becomes  gangrenous  at  once 
This  takes  place  as  follows :  In  the  chief  artery,  say  the  femoral,  along 
the  thigh  or  in  the  hollow  of  the  knee,  a  firm  clot  forms  and  adheres 
CO  the  wall  of  the  vessel  by  rough  prominences  on  the  internal  coat, 
due  to  precedent  atheromatous  disease,  or  else  forms  in  sac-like  dila- 
tations of  the  artery  and  gradually  grows  by  apposition  of  new  fibrine, 
so  as  not  only  to  fill  the  caHbre  of  the  artery,  but  to  plug  up  the  whole 
peripheral  end  of  the  vessel,  and  even  a  portion  of  the  central  end,  by 
the  fibrinous  clot.  The  consequence  of  this  stoppage  of  the  artery  by 
a  thrombus  developing  on  the  wall,  which  gradually  arrests  the  col- 
lateral circulation  also,  is  usually  gangrene  of  the  whole  foot  and  part 
of  the  leg,  which  is  dry  or  moist  according  to  the  rapidity  with  which 
the  clot  has  developed  ;  it  is  occasionally  possible  to  trace  the  growth 
of  the  thrombus  by  the  spread  of  the  gangrene.  Not  long  since  I 
observed  an  old  man,  who  was  taken  into  the  hosj^ital  for  spontaneous 
gangrene  of  the  foot.  He  was  so  thin  and  the  arteries  were  so  rigid 
that  the  pulsations  of  the  femoral  could  be  distinctly  followed  into  the 
hollow  of  the  knee.  Subsequently  the  gangrene  progressed,  and  at 
the  same  time  the  pulsation  in  the  lower  part  of  the  artery  ceased. 
About  a  fortnight  later,  shortly  before  death,  when  the  gangrene  had 
advanced  to  the  knee-joint,  the  pulsation  had  ceased  at  Poupart's  liga- 
ment. Tlie  autopsy  confirmed  the  diagnosis  of  complete  arterial 
thrombosis.  The  gangrenous  leg  was  so  completely  mummified  that  I 
cut  it  from  the  body,  and,  to  preserve  it  from  further  destruction  and 
vvorms,  varnished  it.     It  is  still  in  the  surgical  museum  at  Zurich. 

Another  case  of  arterial  thrombosis  is  where  the  primary  stoppage 
of  the  artery  is  caused  b}'  an  embolus.  A  clot  of  fibrine,  in  endocarditis 
or  detached  from  an  aneurismal  sac,  may  become  wedged  in  an  artery 
of  one  of  the  extremities  ;  this  induces  further  deposit  of  fibrine.  Of 
late,  there  is  a  tendency  to  refer  most  cases  of  softening  and  desiccation, 
as  of  the  brain,  spleen,  etc.,  to  such  emboli.  In  our  clinic  we  saw  a 
very  interesting  typical  case  of  this  variety.     Six  weeks  after  confine- 


360  ERGOTISM. 

ment,  a  j^oung  woman  bad  great  swelling  of  the  left  leg,  which  was 
soon  followed  by  a  dark-blue  color  of  the  skin,  and  complete  putrefac- 
tion of  that  part  of  the  body ;  there  was  general  septic  poisoning 
when  the  patient  entered  the  hospital.  As  there  was  no  excessive 
anasmia,  and  no  disease  of  the  arteries  could  be  discovered,  I  made  the 
diagnosis  of  endocarditis  with  fibrinous  vegetations  on  the  mitral  valve, 
and  detachment  of  one  of  these  vegetations,  with  its  lodgment  at  the 
bifurcation  of  the  left  popliteal  artery.  I  held  to  this  diagnosis,  al- 
though no  abnormal  murmur  could  be  discovered,  for  it  is  well  known 
that  some  cases  of  endocarditis  run  their  course  almost  without  symp- 
toms ;  the  rapid  putrefaction  of  the  leg  must  have  had  a  sudden  cause. 
As  no  line  of  demarcation  formed,  and  the  general  condition  daily 
became  worse,  we  could  have  no  hopes  of  saving  life  by  amputating  ; 
death  took  place  about  twelve  days  after  the  first  symptoms  of  gan- 
grene ;  the  autopsy  fully  confirmed  the  diagnosis.  It  seems  remark- 
able that  no  collateral  circulation  should  develop  in  such  cases,  as  it 
does  after  ligation  of  the  femoral  artery.  I  can  onl}^  explain  this  on 
the  supposition  that  in  endocarditis  the  heart's  action  is  weakeued, 
and  consequently  the  pressure  of  the  blood  is  insufficient  to  dilate  the 
smaller  collateral  arteries. 

Very  rare  are  the  cases  where  from  excessive  anaemia  the  arteries 
are  so  much  contracted  that  but  little  blood  circulates  through  the 
smaller  ones,  and  the  nervous  excitation  of  the  heart  is  so  slight  that 
its  contractions  are  incomplete.  Cases  of  spontaneous  gangrene  from 
this  cause  are  more  frequent  in  slender  chlorotic  females  than  in  men ; 
the  patients,  who  are  generally  young,  often  sufi"er  from  rigidity  of  the 
hands  and  feet,  fainting-fits,  and  fatigue.  This  disease  appears  to  be 
more  frequent  in  France  than  in  Germany  or  England.  There  is  an 
excellent  work  on  the  subject  by  Raynaud^  entitled  "  De  I'asphyxie 
locale  et  de  la  gangrene  symetrique  des  extr^mites,"  18G2.  As  im- 
plied by  the  title,  the  gangrene  is  usually  symmetrical  in  the  two 
limbs.  I  have  only  seen  one  such  case ;  a  young,  very  anaemic  man, 
without  any  apparent  cause,  had  first  gangrene  of  the  tip  of  the  nose, 
then  of  both  feet.  After  sufifering  for  months,  he  died  ;  as  on  the  pa- 
tient, so  on  the  cadaver,  I  could  find  nothing  morbid  beyond  the  ex- 
cessive, inexplicable  anaemia. 

The  form  of  gangrene  seen  from  eating  spurred  rye  is  refened  to 
permanent  spasmodic  contraction  of  the  smaller  arteries ;  experience 
shows  that  this  substance  induces  contraction  of  the  organic  muscular 
fibres,  especially  of  those  of  the  uterus,  and  it  is  supposed  of  the 
uterine  arteries  also. 

Spurred  rye,  secede  comutum,  is  a  diseased  grain  growing  in  the 
ear  of  rye  (secale  cereale),  in  which  is  developed  a  peculiar  material. 


GAXGRENE. 


361 


ergo  tin.  If  bread  be  made  from  such  grain,  persons  eating  it  are 
aifected  with  peculiar  symptoms,  which  are  comprised  under  the  name 
ergotismus  or  raphania.  As  the  above  disease  of  the  grain  is  usually 
Umited  to  certain  regions,  it  may  be  readily  understood  that  the  dis- 
ease should  occur  epidemically  in  men  and  beasts.  It  has  been  known 
for  a  long  time,  but  the  first  accurate  descriptions  are  of  an  epidemic 
in  France  in  1630,  The  disease  seems  to  have  occurred  rarely  in 
Germany,  England,  or  Italy.  Of  late  it  hardly  ever  occurs,  probably 
because  the  diseased  grain  is  better  known  and  is  no  lono'er  used  for 
food,  and  because  less  of  the  grain  is  grown  since  potatoes  have  come 
into  common  use.  From  former  descriptions,  various  forms  and 
courses  of  the  disease  may  be  distinguished,  of  which  sometimes  one 
and  sometimes  another  prevailed  in  the  different  epidemics  ;  possibly 
the  poison  is  not  always  the  same,  or  is  at  least  of  variable  intensity. 
In  the  acute  cases,  the  patients  were  soon  attacked  with  severe  gen- 
eral cramps,  and  death  resulted  in  from  four  to  eight  days ;  cramps 
only  occur  occasionally ;  at  the  same  time,  and  previously  in  the  pro- 
dromal stage,  there  are  great  itching  and  crawling  in  the  skin,  but  par- 
ticularly in  the  hands  ;  therc^  is  also  a  feeling  of  deadness,of  anassthe- 
sia  in  the  ends  of  the  fingers,  rarely  moist  gangrene  of  the  skin,  then 
of  whole  extremities.  In  more  chronic  cases,  the  result  is  usually 
favorable,  although  several  fingers  or  toes  may  be  lost. 

4.  We  have  still  to  speak  of  several  forms  of  gangrene  whose 
causes  are  not  exactly  known,  in  which  probably  several  influences 
unite.  Among  these  is  so-qalled  water-canker,  noma,  a  spontaneous 
gangrene  of  the  cheeks,  especially  common  in  children,  which  is  most 
frequent  in  cities  along  the  Baltic,  and  more  rare  inland.  Very  puny 
children,  living  in  cold,  damp  dwellings,  are  particularly  prone  to  this 
disease,  in  which,  without  any  known  cause,  a  gangrenous  nodule 
forms  in  the  middle  of  the  cheek  or  lip  and  spreads  rapidly  till  the 
child  finally  dies  of  exhaustion.  It  is  doubtful  whether  this  is  due  to 
anosmia  with  feebleness  of  the  heart,  to  miasmatic  influence,  or  to  some 
peculiar  disease  of  the  blood.  In  occasional  remarks  about  septi- 
caemia, we  have  already  stated  that  certain  morbid  states  of  the  blood 
predispose  to  gangrene.  Under  this  cause  we  must  class  the  cases 
occurring  after  typhus,  intermittent  and  exanthematous  fevers,  in 
diabetes  mellitus,  morbus  Brightii,  etc.  After  and  during  these  dis- 
eases, gangrene  of  the  tip  of  the  nose,  of  the  ear,  cheeks,  hands,  and 
feet,  occurs  ;  and  in  rare  cases  an  exanthema  of  the  skin  may  pass  into 
gangrene.  In  such  cases  we  may  consider  that  the  miasma  which  has 
mduced  the  constitutional  disease  also  influences  the  occurrence  of 
the  gangrene ;  and,  on  the  other  side,  there  seems  reason  for  the  idea 
that  these  cases  are  mostly  the  result  of  feeble  action  of  the  heart. 


362  TEEATilENT   OF  GANGREXE. 

induced  by  the  long  illness,  which  proves  insufficient  to  carry  the 
blood  to  the  remote  parts  of  the  body  with  sufficient  energy  ;  accord- 
ing to  this  view,  this  gangTene  would  be  due  to  marasmic  capillary 
thrombosis.  Doubtless  various  circumstances  act  more  or  less  promi- 
nently in  individual  cases,  so  that  no  definite  etiology  can  be  given 
for  these  rare  forms  of  gangrene  from  internal  causes.  I  may  also 
mention  that  stomatitis,  from  excessive  use  of  mercury,  also  has  a 
great  tendency  to  gangrene.  We  shall  hereafter  speak  of  a  peculiar 
form  of  gangrene  of  wounds,  the  so-called  hospital  ganrjrenc. 


There  are  certain  important  prophj'lactic  rules  for  the  prevention 
of  gangrene,  especially  of  decubitus  and  other  forms  due  to  pressure ; 
even  gangrene  from  inflammation  may  sometimes  be  prevented,  by  re- 
lieving the  great  tension  of  the  tissue  and  the  venous  congestion  by 
an  incision  made  at  the  proper  time.  Be  constantly  on  your  guard 
against  bed-sores  in  all  diseases  at  all  disposed  to  decubitus ;  turn 
your  attention  to  this  point  early :  a  well-stuflFed  horse-hair  mattress  is 
the  best  sick-bed ;  the  sheets  placed  over  it  should  always  be  kept 
smooth,  so  that  the  patient  shall  not  lie  on  wrinkles.  As  soon  as  any 
redness  appears  over  the  sacrum,  you  should  be  doubly  careful  about 
the  passages  of  urine  and  fjeces,  so  that  the  bed  may  not  be  wet.  Let 
a  lemon  be  cut  and  the  reddened  spot  rubbed  daily  with  the  fresh  juice 
from  the  cut  surface.  If  there  be  excoriation  over  the  sacrum,  place 
the  patient  on  a  ring  cushion,  or,  if  possible,  on  a  caoutchouc,  air,  or 
water  cushion.  The  excoriation  may  be  painted  Avith  nitrate  of  silver, 
or  covered  with  leather  spread  with  lead-plaster.  If  the  decubitus  be 
gangrenous  from  the  first,  and  this  begins  to  extend,  we  should  resort 
to  the  ordinary  treatment  of  gangrene,  of  Avhich  we  shall  speak  pres- 
ently. 

The  local  treatment  of  gangrene  has  two  chief  objects  :  1.  To  pro- 
mote detachment  of  the  gangrenous  parts  by  exciting  active  suppura- 
tion, which  is  accompanied  by  arrest  of  the  gangrene ;  2.  To  prevent 
the  gangrenous  parts  decomposing,  and  thus  acting  injuriously  on  the 
patient,  and  infecting  the  chamber  too  much. 

For  the  first  indication,  moist  warmtli  in  the  form  of  cataplasms 
was  formerly  employed.  But  I  cannot  find  that  they  are  peculiarly 
efficacious  in  these  cases.  If  the  gangrene  be  moist  and  the  gangre- 
nous parts  are  much  inclined  to  decompose,  this  would  only  be  favored 
by  the  application  of  cataplasms ;  for  the  detachment  of  a  dry  eschar, 
which  does  not  smell  badly,  and  when  the  line  of  demarcation  is  al- 
ready formed,  it  is  hardly  worth  while  to  hasten  the  process  a  little 
by  warmth.     Hence  I  prefer  covering  the  gangrenous  parts  and  the 


GANGREXE. 


363 


l)orders  of  the  healthy  tissue  with  compresses  or  charpie,  soaked  in 
chlorine-water,  and  thus  in  moist  gangrene  I  also  diminish  the  bad 
smell  of  the  decomposing  substances.  For  the  same  purpose,  we  may 
use  creosote-water  or  carbolic  acid,  or  dilute  purified  pyroligneous 
acid,  very  strong  alcohol,  spirits  of  camphor,  or  oil  of  turpentine. 
Charcoal-powder  absorbs  the  gases  from  the  decomposing  substances, 
but,  as  it  soils  the  parts  very  much,  it  is  perhaps  too  little  used.  Other 
powerful  antiseptics  are  acetate  of  alumina  (alum  3  v,  plumbum  aceti- 
cum,  3  j,  aqua,  R  1),  and  coal-tar  with  plaster;  both  remedies  are 
very  serviceable,  but,  like  all  similar  ones,  must  be  freshly  applied 
several  times  daily  to  remove  entirely  the  smell  of  the  decomposing 
parts.  Of  late,  permanganate  of  potash  (gr.  x  to  §  i  water)  has  been 
greatly  praised  as  a  local  antiseptic  and  disinfectant;  I  have  made 
several  trials  of  it,  but  have  found  it  far  inferior  to  the  remedies  pre- 
viously mentioned.  Concentrated  solutions  of  carbolic  acid  in  olive- 
oil  (say  3  ij  to  H)  1)  cause  symptoms  of  poisoning  (olive-green  urine), 
hence  they  should  be  used  carefully.  As  soon  as  the  gangrenous 
mass  has  become  somewhat  detached,  the  shreds  should  be  removed 
with  the  scissors,  without  cutting  into  the  healthy  parts  ;  this  is  par- 
ticularly important  in  gangrene  of  the  subcutaneous  cellular  tissue, 
which  is  often  extensive,  as  after  infiltration  of  urine ;  at  the  same 
time  the  local  antiseptics  should  be  continued  till  healthy  granulations 
arise.  Led  by  the  anatomical  conditions  in  spontaneous  gangrene,  it 
has  been  advised  to  break  up  the  coagulation  of  blood,  by  stroking 
and  rubbing  the  limb ;  from  the  pain  and  swelling  of  the  parts,  this  is 
rarely  practicable  ;  in  cases  where  I  have  had  it  done,  it  has  had  no 
effect  on  the  progress  of  the  gangrene. 

If  the  gangrene  affect  a  limb,  as  in  the  various  forms  of  sponta- 
neous and  senile  gangrene,  I  strongly  urge  you  not  to  do  any  opera- 
tion till  the  line  of  demarcation  is  distinct.  If  there  be  merely  gan- 
grene of  single  toes,  leave  their  detachment  to  Nature ;  if  the  whole 
foot  or  leg  be  affected,  do  the  amputation  so  that  it  may  be  merely 
an  aid  to  the  normal  process  of  detachment,  i.  e.,  on  the  borders  of 
the  healthy  parts  you  try  to  dissect  up  only  enough  skin  to  cover  the 
stump,  and  saw  the  bone  as  near  as  practicable  to  the  line  of  demar- 
cation. Thus  you  will  occasionally  succeed  in  avoiding  a  new  out- 
break of  the  gangrene,  and  in  sa^dng  your  patient's  life.  If  the  patient 
dies  before  a  distinct  line  of  demarcation  has  formed  (as  is  frequently 
the  case),  you  need  not  reproach  yourself  for  having  neglected  am- 
putation, for  you  may  rest  assured  that  the  patient  would  have  died 
even  sooner  if  amputation  had  been  performed.  The  prognosis  in 
gangrene  from  internal  causes  (as  the  older  surgeons  termed  it)  ia 
(generally  bad. 


364  TREATMENT  OF  GANGRENE. 

The  internal  treatment  should  be  strengthening,  in  some  cases 
even  stimulant.  Nourishing  food,  quinine,  acids,  and  occasionally  a 
few  doses  of  camphor,  are  proper.  The  severe  pain  in  senile  gan- 
grene often  calls  for  large  doses  of  opium,  or  subcutaneous  injection 
of  morphine.  For  gangTcne  in  stomatitis,  after  poisoning  by  mercury, 
we  have  no  decided  antidote ;  the  use  of  the  mercurial  should  be  at 
once  stopped;  if  mercurial  salve  has  been  employed,  the  patient 
should  be  bathed,  placed  in  a  fresh,  airy  chamber,  provided  with  clean 
body  and  bedclothes,  and  have  a  gargle  with  chlorate  of  potash  or 
chlorine  water.  Nor  have  we  any  antidote  for  ergotin,  which  causes 
raj^hania ;  emetics,  quim'ne,  and  carbonate  of  ammonia  are  chiefly  rec- 
ommended, ^^''e  could  only  put  ofi"  the  continued  absorption  of  putrid 
matter  into  the  blood,  by  amputation ;  but  we  have  already  mentioned 
that  this  is  a  very  precarious  remedy  in  spontaneous  gangrene. 

At  the  opening  of  this  chapter  I  said,  "  The  immediate  cause  of 
death  of  individual  parts  of  the  body  is  always  the  complete  cessa- 
tion of  the  supply  of  nutriment,  mostly  due  to  arrest  of  circulation 
in  the  capillaries."  This  admits  the  possibility  of  gangrene  occur- 
ring in  tissues  where  cajiillary  circulation  still  continues.  Formerly 
this  seemed  to  me  impossible  ;  I  could  not  imagine  a  dead  gangre- 
nous tissue  with  cajiillary  circulation.  But  observations  at  the  bed- 
side, together  with  the  impressions  derived  from  SamiieVs  investiga- 
tions of  inflammation,  have  made  it  seem  to  me  jirobable  that  the 
inflammatory  disturbance  of  nutrition  of  which  Ave  have  spoken 
occasionally  starts  up  and  extends  so  rapidly  that  it  leads  directly 
to  arrest  of  the  vital  change  of  tissue,  even  before  the  occurrence  of 
stasis  and  coagulation  in  the  capillaries  ;  the  blood  then  circulates 
in  tissues  which  fulfill  no  normal  function  of  intei'change  of  tissue, 
but  in  which  the  juices  are  being  decomposed  in  an  abnormal  way, 
which  may  even  be  the  same  as  putrefaction.  Paronychioe  and 
more  rarely  phlegmons  sometimes  pass  so  rapidly  to  gangrene,  that 
from  analogy  with  other  processes  it  seems  very  imiDrobable  that 
they  should  be  due  to  arterial  thrombosis  ;  when  the  tissue  has  be- 
come gangrenous,  the  capillary  circulation  soon  ceases,  but  not  from 
disturbance  of  the  circulation  in  the  arteries  and  veins,  as  in  gan- 
grene from  incarceration,  but  from  arrest  of  function  of  their  walls 
from  the  inflammatory  process,  which  I  regard  as  a  higher  grade  of 
the  inflammatory  alteration  (  Cohnheim)  that  takes  place  rajjidly  in 
such  cases.  It  seems  that  such  a  rapid  change  from  inflammatory 
alteration  to  destruction  of  tissue  is  particularly  apt  to  follow  septic 
2Doisoning  ;  possibly  snake-poison  acts  in  the  same  way.  More  of 
this  hereafter.  Here  we  must  again  mention  the  fibrinous  infiltra- 
tions of  the  cellular  tissue  (diphtheritic  phlegmons).     Some  clinical 


GANGREXE.  365 

observations  seem  to  show  that  fluid  blood  can  continue  to  flow  for 
a  time  through  the  vessels  of  tissues  whose  juices  have  nearly  hard- 
ened, that  in  some  of  these  cases  the  thrombosis  is  only  the  result 
of  the  infiltration  of  tissue,  and  that  the  tissue  sometimes  dies  be- 
fore the  circulation  is  fully  arrested.  At  present  we  cannot  fully 
explain  this  symptom  ;  I  only  wished  to  induce  you  when  opportu- 
nity offered  to  attend  to  these  practically  impoi'tant  processes.  The 
view  is  not  new,  for  the  old  surgeons  regarded  gangrene  as  the 
highest  point  of  inflammation. 

[Quite  recently  Dr.  F.  von  Winiioarter  has  described  a  case  of 
spontaneous  gangrene  which  has  hitherto  probably  been  classed 
with  atheromatous  embolism.  The  patient  was  fifty-seven  years 
old,  and  for  years  he  had  suffered  from  pains  regarded  as  rheumatic, 
and  then  gradually  gangrene  of  the  toes  and  of  the  foot  came  on, 
and  made  amputation  of  the  thigh  necessary.  Examination  of  the 
vessels  showed  proliferation  of  the  intima  of  the  arteries  and  veins, 
commencing  in  the  large  trunks  and  not  leading  to  any  retrograde 
metamorphosis,  terminating  in  a  cellular  fibrous  mass  obliterating 
the  vessel.  The  media  and  adventitia  hardly  participated  in  this 
process.  The  affection  would  be  a  primary  obliteration  of  the  large 
vessels  by  a  peculiar  form  of  endarteritis  and  endophlebitis,  which 
it  is  practically  important  to  recognize,  as  in  certain  cases  it  might 
induce  us  to  amputate  in  healthy  tissue  before  the  line  of  demarka- 
tion  is  formed,  which  is  not  the  custom  in  cases  of  ordinary  senile 
gangrene.  The  case  above  mentioned  recovered  ;  so  this  mode  of 
treatment  gives  some  hopes. 

It  has  been  previously  stated  that  in  some  persons  cold  causes 
spasmodic  contraction  of  the  arteries  which  induces  temporary  com- 
plete anoemia,  usually  only  in  certain  fingers.  Such  symptoms  have 
also  been  observed  in  patients  in  whom  spontaneous  gangrene  de- 
veloped. If,  from  any  cause,  the  spasm  of  the  arteries  does  not 
subside  the  anoemic  limb  must  become  gangrenous.  These  patients, 
who  are  mostly  youthful,  also  have  other  symptoms  of  disturbed 
circulation,  such  as  faintness  from  cerebral  anaemia,  continued  chilli- 
ness, great  depression,  etc. 

It  is  not  always  the  peripheral  portions  of  the  extremities  that 
are  attacked  by  gangrene,  but  this  may  occur  in  the  skin,  perhaps 
at  symmetrical  parts  of  the  arm  (from  disease  of  the  nerves  of  the 
vessels)  ;  demarkation  occurs,  eschars  fall,  and  the  loss  of  substance 
heals  by  granulation.  This  may  occur  occasionally,  while  in  the 
interval  temporary  disturbances  of  circulation  are  common. 

When  a  patient  has  to  lie  steadily  on  the  back,  the  skin  over  the 
sacrum  and  buttocks  should  be  examined  daily  and  washed  with 


366 


TREATMENT   OF   GANGRENE. 


equal  parts  of  vinegar  and  water,  or,  if  it  has  become  red,  it  may  be 
rubbed  with  a  piece  of  lemon. 

When  gangrene  has  occurred.  Lister's  dressing  may  be  applied. 
It  has  been  advised  in  the  commencement  of  the  disease  to  break 
up  the  blood-clots  by  rubbing  ;  but  this  causes  too  much  jjain,  and 
may  start  off  emboli  to  other  parts. 

If  gangrene  develojis  and  extends  very  slowly,  while  the  gen- 
eral condition  of  the  patient  is  good,  there  is  probably  disease  of 
the  arteries  ;  there  is  no  exact  limit  to  the  gangrene,  still,  in  these 
cases,  amputation  is  indicated  while  the  general  condition  would 
render  it  endurable  ;  but  it  should  be  done  through  healthy  tissue, 
at  some  distance  from  the  gangrene. 

The  form  of  gangrene  called  noma  requires  particularly  ener- 
getic treatment  to  arrest  the  progress  of  the  disease  :  we  should 
remove  the  dead  portion,  and  induce  active  reaction  in  the  healthy 
tissue.  First  the  gangrenous  part,  usually  on  the  cheek,  is  to  be 
divided  by  a  deep  incision  and  the  inliltrated  tissue  scraped  out 
with  a  sharp  scoop,  especially  about  the  gums,  on  whose  border  the 
gangrene  often  creeps  into  the  alveolar  process.  After  removing 
all  that  can  be  taken  away  witli  the  scoop  and  arresting  the  haemor- 
rhage, apply  fuming  nitric  acid  to  the  raw  surface,  so  as  to  cause 
a  firm,  deep  slough  ;  then  fill  the  wound  with  charpie  soaked  in 
acetate  of  ahimina,  and  over  this  apply  moist  wai'mth,  and  change 
this  dressing  twice  daily.  If  the  infiltration  of  the  cutis  progresses, 
touch  the  parts  with  tincture  of  iodine.  The  gangrene  may  thus 
be  arrested  in  some  cases,  and  life  preserved.  The  loss  of  substance 
must  be  replaced  by  plastic  operations.] 


CHAPTER  XIII. 

A  C  CIDENTAL  TEA  U3IA  TIC  AND  INFLAMMA  TOR  T 
DISEASES,  AND  POISONED  WOUNDS. 


LECTURE    XXIV. 

I.  Local  Diseases  ■wliicli  may  accompany  Wounds  and  other  Points  of  Inflammation: 
1.  Progressive  Purulent  and  Purulent  Putrid  Diffuse  Inflammation  of  Cellular 
Tissue. — 2.  Hospital  Gangrene,  Ulcerative  Mucous-salivary  Diphtheria,  Ulcerative 
Urinary  Diphtheria. — 3.  Traumatic  Erysipelas. — i.  Lymphangitis. 

Gentlemen  :  When  speaking  of  traumatic  inflammation,  I  told 
3'ou  that  it  did  not  extend  beyond  the  bounds  of  the  injury,  and  that 
tliis  was  only  apparently  the  case  when  we  could  not  accurately  ex- 
amine the  injured  part.  I  still  maintain  the  truth  of  this.  But  we 
have  already  added  that,  from  various  accidents,  either  immediately 
after  the  injury,  as  in  contused  wounds,  there  may  be  very  severe 
progressive  inflammation,  with  putrefaction,  or  that,  later,  secondary 
inflammations  may  develop  around  the  already  granulating  wound 
from  causes  which  we  mentioned  at  the  time  (Lecture  XIII.).  I  must 
now  tell  you  that  still  another  series  of  peculiar,  partly  inflammatory, 
partly  gangrenous  processes  occur  in  the  wound,  which  cause  severe, 
usually  feverish,  constitutional  diseases.  Some  of  the  latter  may  also 
occur  without  any  thing  peculiar  being  observable  in  the  wound. 
Lastly,  substances  may  enter  a  wound  already  existing,  or  at  the 
time  of  its  occurrence  (as  from  the  bite  of  a  poisonous  or  diseased 
animal),  which  may  induce  both  severe  local  inflammation  and  gen- 
eral blood-poisoning.  In  this  chapter  I  shall  speak  of  all  these 
things ;  I  will  try  to  give  you  a  general  view  of  them.  We  shall 
speak  first  of  the  local  symptoms  which  accidentally  accompany  a 
wound,  or  an  inflammation  due  to  other  causes. 


368 


HOSPITAL   GANGRENE. 


I    LOCAL   DISEASES  WHICH   MAY   ACCOMPANY  "WOUNDS   AND    OTHER 
POINTS  OF  INFLAMMATION. 

1.  For  the  sake  of  comiDleteness,  we  here  mention  again  progres- 
sive svijipurative  and  sanio-purulent  diffuse  inflammation  of  the  cellular 
tissue.  Putrid  matters  which  form  on  fresh  wounds  from  gangrene 
of  the  surfaces  of  the  wound,  and  may  diifuse  rapidly  in  the  meshes 
of  the  cellular  tissue,  occasionally  cause,  on  the  second,  third,  or  fourth 
day,  those  forms  of  inflammation  of  the  cellular  tissue  that  are  char- 
acterized by  rapid  decomposition  of  the  inflammatory  product  and  by 
rapid  extension.  If  the  patient  survives  the  demarkation  of  such  a 
phlegmon,  the  process  always  ends  with  necrosis  of  the  infiltrated 
cellular  tissue  and  panniculus  adiposus.  The  same  thing  occurs  in 
fibrinous  (diphtheritic)  phlegmon.  Both  jDrocesses  are  usually  ac- 
companied by  severe  constitutional  symptoms.  If  suppuration  has 
already  begun,  as  long  as  the  wound  is  open,  phlegmonous  inflam- 
mation may  spread  around  the  wound  from  mechanical  irritation, 
foreign  bodies,  great  congestion,  retention  and  decomposition  of 
pus  in  the  recesses  of  the  wound,  or  infection  of  the  Mound  with 
phlogogenous  substances  of  various  sorts  (Lecture  XXI.). 

2.  Hospital  Gangrene^  Gangrcena  Kosocotnialis ;  Pourriture  de& 
Hopitaux. — I  will  first  describe  the  disease,  then  add  a  few  remarks 
about  the  etiology.  At  a  certain  time  we  notice,  especially  in  hos- 
pitals, that  a  number  of  wounds,  as  well  those  from  recent  oiDcrations 
as  those  that  were  granulating  and  cicatrizing,  without  known  cause, 
become  diseased  in  a  peculiar  manner.  In  some  cases  the  granulat- 
ing surface  changes  partially  or  entirely  to  a  yellow  smeary  pulp, 
which  may  be  washed  off  from  the  surface,  but  more  deeply  it  is 
firmly  adherent.  This  metamorphosis  extends  not  only  to  the  granu- 
lating surface,  but  to  the  surrounding  skin  which  was  previously 
healthy,  which  becomes  rosy-red ;  this  also  assumes  a  smeary  yel- 
lowish-gray color,  and  in  from  three  to  six  days  the  surface  of  the 
original  wound  almost  doubles.  The  increase  in  depth  is  less  in  the 
so-called  pxdpous  form  of  hospital  gangrene.  In  other  cases  a  fresh 
wound,  or  a  granulating  surface,  rapidl}'-  assumes  a  crater  shape, 
excretes  a  sero-putrid  fluid,  after  the  removal  of  which  the  tissues  lie 
exposed.  The  surroimding  skin  is  slightly  reddened.  The  progress 
of  this  molecular  disintegration  to  thin  ichor  is  usuall}'  in  sharply-cut 
circles,  so  that  the  wound  may  acquire  a  horseshoe  or  trefoil  shape. 
This  ulcerous  form  of  hospital  gangrene  progresses  more  rapidl}'"  than 
the  pulpous,  and  extends  with  especial  rapidity  in  depth.  Although 
both  of  the  above  forms  occasionally  occur  separately,  they  are 
also  seen  in  combination.  I  have  seen  the  pulpous  form  oftener 
than  the  ulcerous,  but  acknowledge  that  my  individual  experi' 
ence   of  diphtheria  of  wounds  is  based  on  a  small  number  of  ob- 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,   ETC.  369 

servations.  Hospital  gangrene  does  not  attack  chiefly  large  wounds 
but  rather  insignificant  injuries,  such  as  leech-bites,  cup-cuts,  even 
the  portions  of  skin  denuded  by  a  blister,  while  it  never  occurs  on  an 
uninjured  part  of  the  skin.  The  resemblance  to  diphtheritic  inflam- 
mation of  the  mucous  membranes  is  mentioned  by  some  authors.  But 
after  seeing  a  wound  infected  from  a  diphtheritic  mucous  membrane, 
I  am  convinced  that  dij^htheria  and  hospital  gangrene  are  two  differ- 
ent processes.  A  wound  attacked  by  diphtheria  is  covered  with 
thick  fibrinous  rinds  ;  the  entire  wound  becomes  infiltrated  and  the 
surrounding  parts  intenselj^  erysipelatous  ;  then  a  large  part  of  the 
infiltrated  tissue  becomes  necrosed  and  breaks  down  or  falls  off  in 
shreds.  But  we  do  not  see  the  daily  progress  of  pulpous  degenera- 
tion, forming  round  figures  on  the  margins  of  the  wound,  vt^hich  are 
puffy,  very  sensitive,  and  inclined  to  bleed,  as  is  so  common  in  hos- 
pital gangrene.  It  is  well  known  that  after  diphtheria  of  mucous 
membranes  paralysis  is  not  unfrequent ;  but  this  has  not  been  ob- 
served after  hospital  gangrene.  In  the  latter  disease  there  are  at 
the  same  time  constitutional  symptoms  :  at  first  the  fever  is  not  gen- 
erally severe,  but  there  is  more  or  less  gastric  affection  ;  the  tongue 
is  coated,  there  is  inclination  to  vomit,  and  general  depression. 
The  disease  may  prove  dangerous  to  old  or  debilitated  persons,  es- 
pecially if  it  eats  away  small  arteries  and  causes  arterial  hgemorrhage. 
The  large  arteries  often  resist  hospital  gangrene  wonderfully.  I 
once  saw  a  man,  for  whom  an  inguinal  abscess  had  been  opened,  at- 
tacked by  the  pulpous  form  of  the  disease ;  the  skin  of  the  groin  to 
about  the  size  of  the  hand  was  destroyed ;  the  disease  had  ad- 
vanced so  deep  that  about  an  inch  and  a  half  of  the  femoral  artery 
lay  exposed  in  the  wound,  and  could  be  distinctly  seen  pulsating. 
I  detailed  a  nurse  to  stay  with  the  patient  constantly,  and  to  make 
instant  compression  if  bleeding  should  occur,  as  it  might  at  any  mo- 
ment. The  pulp  was  thrown  off,  the  wound  granulated  rapidly,  and 
after  a  long  time  complete  recovery  took  place  without  haemorrhage. 
The  erysipelatous  redness  accompanying  diphtheritic  phlegmon  and 
hospital  gangrene  is  occasionally  as  sharply  bounded  and  desqua- 
mates as  much  as  in  erysipelas  about  wounds  otherwise  healthy  ;  but 
it  has  not  the  same  tendency  to  spread.  The  constitutional  septic 
poisoning  is  Avorse  in  diphtheria  than  in  hospital  gangrene. 

Views  as  to  the  causes  of  hospital  gangrene  vary  ;  this  is  chiefly 
because  many  living  surgeons  have  had  the  good  or  bad  fortune  never 
to  have  seen  the  disease  ;  thus  in  Zurich  it  has  never  been  seen.  In 
his  maxims  on  military  surgery  Stromeyer  states,  as  a  young  physician 
in  the  Berlin  Charite,  he  had  only  seen  one  case  of  hospital  gangrene. 
Surgeons  who  have  not  seen  this  disease,  or  have  only  seen  sporadic 
25 


370  HOSPITAL   GAXGREXE. 

cases,  think  it  is  due  to  gross  neglect,  dirty  dressings,  etc.,  and  regard 
it  as  little  more  than  an  ulcer  of  the  leg  that  has  superficially  become 
gangrenous  from  dirt  and  neglect.  Other  surgeons  suppose  that  hos- 
pital gangrene  is,  as  the  name  would  indicate,  a  disease  peculiar  to 
some  hospitals,  and  that  its  occurrence  is  only  promoted  by  neglect 
of  the  dressino-s.  Lastly,  a  third  view  is  that  this  form  of  gangrene  is 
due  to  epidemic  influences,  and  that  its  name  is  in  so  far  incorrect  as 
it  occurs  outside  and  inside  of  hospitals  at  the  same  time.  In  the 
hospitals  it  probably  spreads  by  inoculation,  for  I  do  not  doubt  that 
matter  can  be  carried  from  gangrenous  to  healthy  wounds  by  forceps, 
charpie,  sponges,  etc.,  and  there  excite  the  disease.  Voii  Pitha  and 
Fock  have  expressed  the  belief  that  it  is  an  epidemic-miasmatic  dis- 
ease. In  the  surgical  chnic  at  Berlin  with  FocJc  I  observed  an  epi- 
demic, while  the  disease  was  seen  not  only  in  other  hospitals  in  Ber- 
lin, but  in  the  city,  in  patients  who  could  not  be  proved  to  have  had 
anv  thing  to  do  with  a  hospital.  The  disease  appeared  very  suddenly, 
and  entirelv  disappeared  in  a  few  months,  although  the  treatment  of 
the  wounds  had  not  been  at  all  changed,  nor  could  any  changes  be 
made  in  the  hospital  itself.  This  seems  to  show  that  the  causes  do 
not  lie  in  the  hospital  itself.  Epidemic  hospital  gangrene  might  oc- 
cur from  certain  small  organisms,  which  are  rarely  developed,  which, 
like  a  ferment,  induce  decomposition  in  the  wound  and  granulating 
tissue  ;  hence  I  should  preferably  compare  this  disease  of  wounds 
with  blue  suppuration,  which  causes  no  injury  to  the  wounds,  but, 
according  to  LiicJce,  like  blue  milk,  is  caused  by  small  organisms  and 
can  infect  other  wounds.  The  requirements  for  the  growth  of  these 
small  bodies  are  probably  particularly  favored  by  certain  atmospheric 
influences  :  hence  the  disease  spreads  epidemically.  There  is  no 
doubt  that  in  the  pulp  of  every  hospital  gangrene  micrococci  and 
streptococci  are  just  as  frequent  as  in  the  secretion  of  simple  diph- 
theritic wounds.  But  it  has  not  been  proved  that  they  were  in  the 
tissue  before  it  was  destroj-ed,  that  tliey  grew  in  it,  or  broke  it 
down  into  pulp  ;  nor  has  it  been  shown  that  this  is  a  peculiar  va- 
riety of  micrococcus.  But  it  is  certain  that  the  transfer  of  hospital 
gangrene  pulp  or  putrid  matter  to  healthy  wounds  usually  (always, 
according  to  Fischer)  induces  hospital  gangrene,  and  this  is  very 
important  in  practice.  From  my  recent  experience  in  the  Vienna 
General  Hospital,  I  am  more  and  more  convinced  that  this  disease 
results  from  specific  causes,  entirely  independent  of  pyaemia,  septi- 
caemia, erysipelas,  and  lymphangitis,  although  it  ma\-  be  followed 
by  either  of  these  diseases. 

The  first  point  in  the  treatment  is  strict  isolation  of  the  patients, 
who  should  have  special  nurses,  dressings,  and  instruments.     If  this 


TRAUMATIC  AND   INFLAMMATORY  DISEASES,   ETC.  371 

does  not  entirel}^  prevent  the  spread  of  the  disease,  as  the  contagion 
may  possibly  be  carried  by  the  air  from  a  diseased  to  a  healthy 
wound,  still  experience  shows  that  it  interferes  with  the  spread.  In 
some  epidemics  in  militarj^  hospitals  it  was  necessary  entirely  to  va- 
cate certain  localities.  Locally  we  should  apply  strong-  chlorine- 
water,  or  spirits  of  camphor  or  turpentine,  to  these  wounds.  Some- 
times painting  the  part  every  two  hours  with  tincture  of  iodine  acts 
well,  or  solution  of  acetate  of  alumina  applied  on  a  compress  till  the 
wound  becomes  clean;  but  the  solution  should  not  be  too  concen- 
trated, and  its  application  should  be  stopped  when  the  process  ceases 
to  spread.  If  this  also  prove  ineffectual,  it  has  been  recommended 
to  burn  the  wound  down  to  the  healthy  tissue,  so  that  tlie  slough 
shall  remain  attached  six  or  eight  daj's,  as  in  a  healthy  wound.  I 
find  it  just  as  effectual  to  cauterize  the  wound  with  fuming  nitric 
acid  or  carbolic  acid,  but  these  cauterizations  also  should  extend  to 
the  health}^  borders  of  the  wound,  and  be  repeated  till  the  slough 
remains  adherent.  The  general  treatment  should  be  strengthening, 
or  even  stimulant.  The  fever  occurring  in  hospital  gangrene  is  due 
to  reabsorption  of  putrid  matter,  and  does  not  differ  from  other 
forms  of  putrid  fever. 

The  pulpous  phagedenic  gangrene  above  described  is  especially 
apt  to  occur  in  wounds  of  the  mouth  or  urinary  bladder,  even  with- 
out any  external  source  of  infection.  I  mention  this  here  because 
these  diseases  are  doubtless  allied  to  phagedenic  diphtheria,  al- 
though, from  their  limitation  to  certain  parts  of  the  bod}',  they  more 
properly  belong  to  special  surgery  and  the  clinic.  After  extirpation 
of  large  portions  of  the  tongue  and  resection  of  the  lower  jaw,  I 
have  sometimes  seen  a  rapid  pulpy  breaking  down  of  the  wound  fol- 
lowing hard  and  extensive  infiltration  of  the  cellular  tissue  ;  here 
there  is  a  combination  of  diphtheritic  phlegmon  with  phagedenic 
ulceration.  Most  of  these  cases  ended  fatally  from  septica?mia  ; 
others  recovered  after  the  whole  cellular  tissue  had  become  necrosed 
and  been  thrown  off  by  free  suppuration.  Although  mucus  and 
saliva  coming  in  contact  with  these  wounds  may  have  no  phlogoge- 
nous  or  septic  qualities  of  their  own,  putrid  ferments  may  be  mixed 
with  them,  such  as  are  occasionally  found  in  the  coating  on  the  gums 
and  between  the  teeth  of  patients  who  do  not  clean  their  mouths  ha- 
bituallv,  or  neglect  this  on  account  of  painful  ulcers  in  the  mouth. 
So  this  ferment  will  be  carried  to  wounds  in  the  mouth  by  the  mu- 
cus and  saliva,  thus  justifj-ing  the  name  niucous  salivart/  dip/tt/teria. 
This  disease  only  threatens  the  patient  during  the  first  five  days 
after  operation  ;  only  recent  wounds  in  the  mouth  are  infected  by 
the  ferment  in  question ;  if  good  granulations  have  once  developed, 


372  HOSPITAL  GANGRENE. 

this  diphtheria  does  not  occur,  unless  there  be  infection  from  with- 
out, or  the  wound  be  mechanically  injured  and  the  granulations 
partly  destroyed.  In  this  disease  the  constitutional  symptoms  may 
be  very  severe,  and  the  patients  are  particularly  subject  to  sudden 
collapse,  which  is  the  more  dangerous  as,  from  tlie  imjDairment  of 
nutrition  which  has  often  gone  before,  the  patients  are  usually  much 
debilitated. 

After  operations  for  stone,  urethrotomy,  vesico-vaginal  fistula, 
or  ectopia  vesicae,  pulpous  breaking  down  of  the  edges  of  the  wound, 
with  fibrinous  coating  of  the  walls  of  the  bladder  or  of  the  vagina, 
is  not  rare,  especially  when  the  urine  is  alkaline.  As  this  disease  is 
associated  Avith  decomposition  of  the  urine,  it  is  called  urinary  di2'>h- 
theria.  This  form  of  diphtheria  is  the  mildest  of  those  above  men- 
tioned, from  having  little  tendency  to  spread,  and  running  its  course 
without  constitutional  symptoms,  if  the  wound  is  kept  clean.  Rarely 
the  mucous  membranes  break  down,  but  more  frequently  the  process 
becomes  a  purulent  retroperitonitis,  which  becomes  a  peritonitis 
and  causes  death.  Diphtheritic  inflammation  of  the  vagina  also 
may  spread  as  superficial  suppui'ation  to  the  inner  surface  of  the 
uterus,  and  thence  through  the  oviducts  to  the  peritoneum  ;  this 
suppurative  peritonitis  also  is  usually  fatal.  Under  such  circum- 
stances I  have  never  seen  fibrinous  inflammations.  In  the  latter 
cases,  which  unfortunately  are  not  rare  after  confinement,  but  do  not 
often  occur  after  operations  for  vesico-vaginal  fistula,  severe  consti- 
tutional symptoms  are  early  manifested. 

In  the  puljD  from  mucous-salivary  and  from  urinary  diphtheria 
micrococci  and  streptococci  are  constantly  found  ;  they  are  just  as 
regularly  found  in  the  coating  of  the  gums  and  tongue,  and  in  urine 
which  has  become  alkaline,  but  seem  to  develop  with  particular  ra- 
pidity in  this  pulp.  The  contagious  principle  of  this  pulp  has  not 
yet  been  separated  from  the  micrococcus;  so  we  may  suppose  the 
latter  has  in  or  on  it  the  contagious  material.  There  is  no  proof 
that  micrococci  from  any  source  can  excite  this  process  ;  but  many 
observations  tend  to  show  that  these  vegetations  take  up  contagious 
substances  very  readily,  and  so  become  vehicles  of  contagions  and 
ferments.  If  we  inoculate  the  cornea  of  a  rabbit  with  a  fluid  con- 
taining micrococci,  the  interesting  experiments  of  JVassiloJf,  Eherth^ 
Leher,  Stromeyer,  Dolschenkoic,  OrtJi,  Frisch,  and  others  show  that 
the  coccus  grows  to  a  certain  point,  and  in  some  cases  (when  unac- 
companied by  any  peculiarly  injurious  substances)  causes  irritation, 
chiefly  mechanically,  by  separating  the  corneal  lamelljfi,  so  that  the 
coccus  colony  gradually  becomes  enveloped  in  pus,  and  then  is 
thrown  off  with  the  pus  ;  but  in  other  cases  (if  the  inoculated  mat- 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC. 


373 


ter  has  very  deleterious  properties)  the  whole  cornea  may  become 
gangrenous  in  twenty-four  hours,  and  the  growth  of  the  coccus 
hardly  be  as  great  as  in  the  first  instance.  Lastly,  cases  occur  where 
the  coccus  growth  induces  no  reaction  in  the  cornea,  but  disappears 
without  leaving  a  trace;  this  is  even  the  rule  in  inoculating  the 
cornea  of  the  dog. 


Fig.  60  a. 


a,  Fungrtis  from  the  cornea  of  a  rabbit ;    coccus  proliferation  between  the  lamellae  of  the  cornea,  in- 
duced by  inoculation  ;   slightly  magnified,    b,  One  point  of  a,  magnified  600.    After  Friseh. 


From  this  it  follows  that  the  intensity  and  nature  of  inflamma- 
tions induced  by  such  contagions  do  not  depend  on  the  coccus  pro- 
liferation itself,  but  on  the  injurious  qualities  of  the  matter  conveyed 
with  the  coccus. 

I  thought  you  should  be  told  these  things,  so  that  you  would 
have  some  knowledge  about  processes  which  are  now  so  much  dis- 
cussed. I  recommend  for  your  special  study  the  excellent  mono- 
graph on  hospital  gangrene  by  C.  Heine. 

3.  Mysij)elas  trcmmaticmn.  Erysipelas,  as  previously  mentioned 
(page  304),  is  classed  among  the  acute  exanthemata,  and  is  charac- 
terized by  a  diflFuse  swelling,  rosy  redness  of  the  skin,  and  pain,  as 
well  as  by  the  accompanying  fever,  which  is  usually  severe.  Erysip- 
elas has  a  peculiar  relation  to  the  other  exanthemata  ;  on  the  one 
hand,  because  it  often  accompanies  wounds,  although  it  may  appar- 
ently come  spontaneously ;  on  the  other  hand,  because  it  does  not 
generally  spread  by  such  an  intense  contagion  as  measles,  scarlatina, 
etc. ;  lastly,  also  because,  when  one  has  had  this  disease,  he  is  not 
only  not  safe  from  another  attack  of  it,  but  in  some  cases  is  even  pecu- 
liarly predisposed  to  it.  As  I  dare  hardly  assume  that  you  have  al- 
ready studied  skin-diseases  carefully,  Ave  will  here  briefly  review  the 
symptoms  of  this  disease. 

Its  commencement  may  vary  by  the  fever  preceding  the  exanthema, 


374  ERYSIPELAS   TRAUMATICUM. 

or  by  their  simultaneous  appearance.  Suppose  you  have  a  patient 
with  a  suppurating  wound  of  the  head,  and  after  he  has  been  previ- 
ously well,  and  the  wound  was  healing  nicely,  you  find  him  with  high 
fever,  which  may  have  been  preceded  by  a  chill ;  you  examine  the  pa- 
tient, and  can  find  nothing  but  some  gastric  derangement,  as  evinced 
by  a  coated  tongue,  bad  taste  in  the  mouth,  nausea,  and  loss  of  appe- 
tite. This  state  is  present  at  the  onset  of  so  many  acute  diseases 
that  you  cannot  at  once  make  a  diagnosis.  Besides  the  possibility  of 
an  accidental  complication  with  any  acute  internal  disease,  you  would 
think  of  phlegmon,  lymphangitis,  and  erysipelas.  Perhaps  twenty-four 
hours  later  you  find  the  wound  dry,  discharging  a  little  serous  secre- 
tion ;  for  some  distance  around  there  are  swelling,  redness,  and  pain, 
or  the  granulations  are  large,  swollen,  and  croupous  ;  the  redness  of  the 
skin  is  of  a  rosy  hue  and  everywhere  sharply  bounded  /  the  fever  is 
still  tolerably  intense ;  now  the  diagnosis  of  erj'sipelas  cannot  be  mis- 
taken, and  we  are  well  content  that  we  have  to  deal  with  a  disease 
which,  although  not  free  from  danger,  is  one  of  the  less  dangerous  of 
the  traumatic  diseases.  In  a  second  series  of  cases  the  erysipelas  ap- 
pears with  the  fever.  We  may  for  a  brief  period  doubt  whether  the 
case  be  one  of  lymphangitis,  inflammation  of  the  subcutaneous  cellular 
tissue,  or  of  erysipelas,  but  the  course  of  the  disease  will  soon  show 
this ;  the  extent  that  the  erysipelatous  inflammation  of  the  skin  has 
the  first  day  rarely  remains  the  same,  but  it  usually  spreads  farther 
and  farther,  in  such  a  way  that  the  rounded,  tongue-shaped,  project- 
ing borders  of  the  inflamed  skin  are  always  sharply  bounded,  and  we 
can  accurately  follow  its  removal  fi'om  owe  side  to  the  other;  in  many 
cases  the  redness  advances  like  fluid  in  bibulous  paper.  Thus  the 
process  may  extend  from  the  head  to  the  neck,  thence  to  the  shoul- 
ders, or  the  anterior  part  of  the  trunk,  or  even  pass  down  the  arm,  and 
finally  may  even  reach  the  lower  extremities.  Pfler/er  has  observed 
that  the  mode  of  extension  of  wandering  erysipelas  is  almost  always 
the  same,  and  is  probably  due  to  the  flow  of  certain  fluids  (Ij'mph), 
which  again  depends  on  the  arrangement  of  the  filaments  of  the  cutis. 
As  long  as  the  erysipelas  spreads  in  this  way,  the  fever  usually  remains 
at  the  same  height,  and  thus  old  or  debilitated  persons  are  readily 
exhausted.  Most  cases  last  from  two  to  ten  days  ;  it  is  rare  for  one  to 
continue  over  a  fortnight ;  the  most  protracted  case  I  have  seen  was 
one  lasting  thirty-two  days  and  recovering.  In  this  erysipelas  ambulans 
or  serp>ens  j-ou  will  notice  that  the  same  grade  of  inflammation  of  the 
skin  only  continues  a  certain  length  of  time  in  one  place,  so  that  when 
the  erysipelas  advances,  the  whole  surface  is  not  inflamed  at  once, 
but  only  a  part  at  a  time  is  at  the  acme  of  the  local  inflammation. 
After  the  inflammation  has  remained  at  the  same  point  about 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,   ETC.  375 

three  days,  the  redness  grows  less,  the  skin  desquamates,  partly  as  a 
bran-like  powder,  or  in  scales  and  tags  of  epidermis.  In  some  cases, 
even  at  the  commencement  of  the  erysipelas,  the  epidermis  rises  in 
vesicles,  which  are  filled  with  serum  [erysipelas  bullosum).  But  this 
erysijoelas  is  not  a  peculiar  form  of  the  disease ;  it  only  indicates  rapid 
exudation.  We  not  unfrequently  see  vesicles  appear  on  the  face  in 
erysipelas,  while  on  the  rest  of  the  body  the  disease  has  the  usual 
form.  If  erysipelas  attacks  the  scalp,  the  hair  often  falls,  but  grows 
again  quickly.  According  to  my  experience,  the  disease  is  most  fre- 
quent on  the  lower  limbs,  then  on  the  face,  upper  extremities,  breast 
and  back,  head,  neck,  and  belly.  This  scale  of  frequency  probably 
depends  on  the  proportionate  numbers  of  injuries  in  the  different 
parts  of  the  body. 

Erysipelas,  like  other  exantliemata,  may  be  accompanied  by  vari- 
ous internal  diseases,  as  pleurisy,  and  erysipelas  capitis  by  meningitis  ; 
but,  on  the  whole,  these  complications  are  rare,  and  when  they  occur 
are  usually  a  result  of  the  disease  advancing  to  the  deeper  parts. 

The  course  of  erysipelas  is  usually  favorable.  Of  one  hundred  and 
thirty-seven  cases  of  the  uncomplicated  disease,  which  I  observed  in 
Zurich,  ten  died ;  cliildren,  old  persons,  and  patients  debilitated  by 
previous  disease  are  most  endangered,  and,  according  to  my  experi- 
ence, they  usually  die  of  exhaustion  from  the  continued  fever  ;  on 
autopsy,  we  find  no  remarkable  change  of  any  organ  that  can  be  re- 
garded as  the  cause  of  death.  Cloudy  swelling  and  partial  granular 
degeneration  of  the  liver,  kidneys,  and  epithelium,  and  softness  of  the 
spleen,  are  found  in  cases  of  fatal  erysipelas,  as  after  all  intense  blood- 
diseases.  The  nature  of  erysipelas  is  not  fully  understood,  as  its  cause 
and  the  mode  of  its  progress  are  not  quite  clear.  Dilatation  of  the 
capillaries  of  the  cutis,  serous  exudation  in  the  tissue  itself,  and  an 
active  development  of  the  cells  of  the  rete  Malpighii  are  all  we  can 
find  anatomically.  The  disease  rarely  extends  to  the  subcutaneous 
cellular  tissue  ;  it  is  true,  this  swells  enormously  in  some  places,  as 
in  the  eyelids  and  scrotum,  being  greatly  saturated  with  serum  ;  but 
in  most  cases  this  oedema  recedes  without  any  sequela?.  In  rare  cases 
this  oedema  attains  such  a  grade  that,  as  a  result  of  the  great  distention 
of  tissue,  the  circulation  of  blood  is  arrested,  and  the  parts  (as  the  eye- 
lids) may  become  wholly  or  partly  gangrenous.  Should  all  the  skin 
of  an  upper  or  lower  eyelid  be  lost  in  this  way,  it  would  cause  great 
deformity  ;  but  usually  only  small  portions  mortify,  and,  in  the  upper 
lid  particularly,  the  skin  is  so  plenty  in  most  persons  that  the  defect 
is  subsequently  but  little  noticed.  In  other  cases,  after  the  subsi- 
dence of  the  erysipelatous  inflammation,  there  remains  a  swelling  of 
the  subcutaneous  tissue,  in  which  we  may  distinctly  feel  fluctuation, 


376  ERYSIPELAS   TRAUMATICUM. 

and  by  incision  may  evacuate  pus.  Microscopic  examination  of  skin 
affected  with  erysipelas  shows  only  more  or  less  infiltration  of  the 
cutis  and  subcutaneous  tissue. 

The  causes  of  erysipelas  evidently  vary  ;  that  occurring  without  a 
wound,  spontaneous  erysipelas  capitis,  is  said  to  come  most  frequently 
after  catching  cold.  Some  old  persons  are  said  to  have  this  disease 
every  year,  in  spring  or  autumn  ;  psychical  influences  are  also  blamed 
for  it,  especially  terror,  particularly  in  women  during  their  menses. 
I  cannot  vouch  for  the  latter,  but  think  it  may  belong  to  medical 
traditions.  Disturbances  of  digestion  are  also  regarded  as  causes. 
I  am  very  skeptical  of  all  the  views  which  are  not  based  on  accurate 
observation,  but  rest  on  tradition ;  indeed,  I  consider  it  doubtful 
whether  erysipelas  ever  occurs  without  having  started  from  a  wound 
or  some  point  of  inflammation  already  existing. 

From  what  I  have  seen  of  erysipelas  traumaticum,  my  idea  con- 
cerning' it  is  as  follows  :  I  consider  the  local  afi'ection  as  an  inflamma- 
tion of  the  cutis,  in  which  the  inflammatory  irritation  gradually 
spreads  through  the  lymphatic  net-works  ;  the  way  in  which  the  in- 
flammatory redness  spreads  and  is  sharply  bounded  shows  positively 
that  the  process  is  limited  to  the  vascular  districts  ;  by  close  observa- 
tion we  may  see  that  very  often,  close  to  the  border  of  the  redness, 
there  forms  a  red,  round  spot,  at  first  circumscribed,  which  soon 
unites  with  the  previously-reddened  portions  of  skin ;  these  newly- 
forming  red  spots  evidently  represent  vascular  districts  ;  we  see 
something  similar  when  we  inject  the  skin  through  an  artery  ;  then, 
too,  the  color  from  the  injection  first  appears  in  spots,  and  only  unites 
when  heavy  pressure  is  made  on  the  syringe;  now,  as  the  venous  and 
lymphatic  districts  in  the  skin  are  to  some  extent  analogous  to  the 
arterial,  the  irritating  poison  causing  the  dilatation  of  the  blood- 
vessels might  circulate  in  one  of  these  tracts.  The  arterial  and 
venous  tracts  in  the  cutis  have  few  connecting  branches  parallel  to  the 
surface,  while  the  lymphatic  vessels  have  very  many,  and  but  few 
branches  going  down  into  the  subcutaneous  tissue  ;  thus  the  exciting 
poison  may  readily  spread  superficially  in  the  cutis,  like  liquid  in  bibu- 
lous paper,  but  it  also  enters  the  subcutaneous  lymphatics,  and  often 
causes  inflammation  there,  as  well  as  in  the  neighboring  lymphatic 
glands,  striated  redness  of  the  skin,  and  swelling  of  the  adjacent 
lymphatic  glands.  When  I  here  speak  of  a  septic  or  other  similar 
poison  as  a  cause  of  erysipelas,  I  refer  only  to  traumatic  erysipelas, 
for  I  think  I  have  satisfied  myself  by  observation  that  this  is  always 
of  toxic  origin.  Concerning  the  nature  of  this  poison,  I  may  sa}' : 
1.  It  is  chiefly  blood  mixed  with  decomposing  secretion  from  the 
wound  that  induces  erysipelas,  which  then  appears  the  second  or 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,   ETC.  377 

third  day  after  the  injury  or  operation.  2.  There  is  probably  a  dry, 
dust-like  substance,  which,  coming-  ou  the  wounds,  whether  fresh  or 
granulating,  causes  erysipelas  ;  this  substance  clings  especially  to 
sponges  and  dressings.  I  have  often  observed  that  patients  ojDerated 
on  after  each  other,  under  the  same  circumstances,  in  the  same 
operating-room,  all  had  erysipelas  on  the  fresh  wounds  a  few  hours 
after  the  operation,  without  retention  of  secretion  from  the  wound, 
although  tliey  lay  in  perfectly  separate  wards  of  the  hospital.  Ery- 
sipelas thus  becomes  domesticated  in  the  hospital ;  the  infectino-  sub- 
stance may  be  transported  on  the  clothes  of  the  surgeons  making  the 
dressings ;  it  may  adhere  to  instruments,  beds,  or  even  to  the  walls. 
The  more  accurately  I  examined  the  cases  of  erysipelas  in  the  Zurich 
hospital,  and  in  my  clinic  in  Vienna,  the  more  evident  was  its  occvn-- 
rence  in  groups — an  occurrence  entirely  independent  of  all  other 
morbid  influences  outside  of  the  hospital.  From  statistics  during 
two  years,  supported  by  contributions  from  the  physicians  of  the 
Canton  Zurich,  I  have  found  that  during  that  time  erysipelas  had  not 
occurred  epidemically  in  the  country  or  city,  but  that,  like  other 
acute  diseases,  it  was  particularly  frequent  in  autumn  and  spring  ; 
hence  erysipelas  epidemics  in  hospital  must  depend  on  circumstances 
that  are  to  be  sought  in  the  hospital  itself,  and  which  I  have  already 
indicated.  Here  arises  the  question  whether  the  poison  which  excites 
erysipelas  is  alwaj's  the  same,  whether  it  is  specific.  This  cannot  be 
accurately  answered  :  in  its  favor  is  the  fact  that  the  form  of  the  cu- 
taneous inflammation  induced  is  always  the  same,  although  varying 
In  intensity  and  extent  ;  against  it  we  may  say  that  erysipelas  is 
probably  caused  by  various  kinds  of  putrefaction,  by  miasma,  per- 
haps also  by  some  animal  poisons.  Possibly  in  all  of  these  poison- 
ous substances  there  might  be  one  certain  material  w^hich  induced 
erj'sipelas,  particularly  a  variety  of  material,  which  had  a  specific  affin- 
ity for  the  lymphatic  vessels  of  the  skin  ;  it  must  be  acknowledged 
that,  under  certain  circumstances,  existing  at  some  particular  time, 
such  a  material  may  develop  more  readily  and  extensively  than  at 
other  times.  It  has  often  been  asserted,  and  of  late  more  particu- 
larly by  Orth,  that  erysipelas  extends  by  micrococcus  vegetation 
from  the  wound  to  the  skin.  Although  the  spread  and  reproduction 
of  the  erysipelas  contagion  much  resemble  those  of  a  ferment,  there 
is  as  yet  no  proof  that  in  erysipelas  the  micrococcus  is  the  bearer  of 
such  a  ferment,  still  less  that  it  is  only  micrococcus.  I  do  not  up- 
hold the  correctness  of  this  view.  I  have  sometimes  found  coccus 
and  streptococcus  in  the  serum  of  erysipelas  vesicles,  but  they  are 
also  found  in  blisters  from  burns  or  sweating,  in  small-pox  pustules, 
etc.  ;  and  this  is  no  proof  that  these  diseases  are  due  to  micrococ- 


378  ERYSIPELAS  TRAUMATICUM. 

cus.  It  is  doubtful  whether  the  supiDurations  induced  in  rabbits  by 
inoculation  with  the  serum  from  erysipelas  blisters  is  identical  with 
the  erysipelas  of  man.  The  most  recent  work  on  erysipelas,  by 
LuJcomsky,  shows  the  near  relation  of  micrococcus  to  erysipelas  ; 
I  can  confirm  his  observations  from  others  made  at  my  clinic  by 
Ehrlich  ;  but  interesting  as  these  are,  they  cannot  settle  the  vexed 
question  as  to  the  etiology  of  erysipelas.  The  disease  always  begins 
with  a  rapidly-increasing  fever,  which  continues  as  long  as  the 
eruption  lasts ;  it  may  be  either  remittent  or  continued,  sometimes 
terminates  with  critical  symptoms,  sometimes  gradually,  I  have 
no  extensive  experience  of  the  so-called  idiopathic  er3'sipelas  capitis 
et  faciei  ;  from  what  I  have  seen,  it  seems  to  me  very  probable 
that  this  also  starts  from  slight  wounds  (excoriations  on  the  head  or 
face)  or  inflammations  (nasal  catarrh,  angina),  and  is  also  chiefly  of 
toxic  origin. 

The  treatment  of  erysipelas  is  chieflj'  expectant.  We  may  try 
prophylaxis  by  carefully  cleansing  the  wound,  and  thus  keeping  off 
every  thing  that  can  favor  the  occurrence  of  erysipelas  ;  and  Avhcn 
several  cases  occur  in  hospital,  we  should  carefully  guard  against  too 
many  of  them  being  in  one  ward,  and  occasionally  some  of  the  wards 
should  be  entirely  vacated  and  ventilated  for  a  time,  to  prevent  the 
development  of  a  more  intense  erysipelas  contagion  (little  as  we  cer- 
tainly know  of  it). 

As  to  the  local  treatment,  a  series  of  remedies  has  been  tried  to 
prevent  the  advance  of  the  erysipelatous  inflammation  and  arrest  the 
disease  at  its  commencement.  For  this  purpose  we  circumscribe  the 
borders  with  a  stick  of  moist  nitrate  of  silver  or  with  strong  tincture 
of  iodine.  According  to  my  experience,  this  does  little  good,  so  that 
of  late  I  have  entirely  left  off  this  treatment.  Older  physicians 
thought  that  cold  might  force  the  cutaneous  inflammation  back,  and 
thus  greatly  favor  inflammation  of  the  internal  organs.  Although 
this  cannot  be  regarded  as  proved,  a  series  of  facts  renders  the  use  of 
cold  apparently  unadvisable.  "VYe  have  already  mentioned  that  the 
occasionally  great  oedema  may  induce  gangrene,  which  of  course  would 
be  greatly  favored  by  intense  cold  ;  and  the  application  of  bladders 
of  ice  to  a  large  surface,  as  to  the  back  or  the  whole  face,  is  scarcely 
practicable ;  lastly,  the  ice  does  no  good,  as  in  spite  of  it  the  dis- 
ease runs  its  typical  course,  for  here  almost  more  than  in  any  other 
inflammation  the  local  process  and  general  infection  go  hand  in 
hand.  In  the  affected  skin  the  patient  has  a  disagreeable  tension, 
a  slight  burning,  as  well  as  great  sensitiveness  to  draughts  or  other 
changes  of  temperature.  Hence  it  is  advisable  to  cover  the  diseased 
skin  and  protect  it  from  the  air.     This  may  be  done  in  various  ways  : 


TRAUMATIC  AND   INFLAMMATORY   DISEASES,  ETC.  379 

tlie  simplest,  wliicli  I  usually  employ,  is  to  smear  the  surface  witli  oil 
and  apply  wadding ;  the  patients  are  generally  satisfied  with  this. 
Others  sprinkle  the  inflamed  skin  with  flour  or  powder,  or  scatter 
finely-rubbed  camphor  in  the  wadding  that  is  to  be  applied,  thinking 
thus  to  act  specially  on  the  local  process.  If  vesicles  form,  they  should 
be  opened  with  fine  needle-punctures,  and  the  loosened  epidermis  be 
left  to  dry.  If  gangrene  develop  anywhere,  moist  warmth  in  the 
form  of  fomentations  or  poultices  should  be  applied  till  the  eschar  has 
detached  and  healthy  suppuration  begun,  which  is  then  favored  by 
dressings  of  charpie  dipped  in  chlorine-water.  If,  after  erysipelas, 
abscesses  form  in  the  subcutaneous  tissue,  they  should  be  opened  early 
and  treated  like  any  suppurating  wound. 

Among  the  internal  remedies,  we  have  one  which  may  perhaps 
arrest  the  development  of  some  cases  of  the  disease.  If  in  strong, 
otherwise  healthy  persons,  in  whom  the  gastric  symptoms  are  very 
prominent,  we  give  an  emetic,  the  advance  of  the  erysipelas  is  often 
checked.  This  is  not  absolutely  reliable,  but  you  may  try  it  in  suit- 
able cases.  Subsequently  3'ou  employ  only  the  ordinary  cooling  reme- 
dies. If  symptoms  of  debility  show  themselves  and  the  disease  drag 
on,  you  should  begin  with  tonics  and  stimulants  ;  you  may  daily  give 
a  few  grains  of  camphor  or  quinine,  or  some  wine. 

The  inflammations  of  internal  organs  occasionally  complicating 
erysipelas  are  to  be  treated  lege  artis,  and  in  meningitis  you  must  not 
be  afraid  to  keep  a  bladder  of  ice  constantly  on  the  head,  even  if  the 
scalp  is  affected  by  the  erysijDelatous  inflammation. 

4.  lyiflammation  of  the  lymphatic  vessels  [lymphangitis),  actual 
inflammation  of  the  lymphatic  vessels,  occasionally  occurs  in  the  ex- 
tremities under  various  circumstances,  which  will  be  mentioned  im- 
mediately. The  symptoms,  in  the  arm  for  instance,  are  as  follows : 
There  is  a  wound  of  the  hand ;  the  whole  arm  becomes  painful,  espe- 
cially on  motion ;  the  axillary  glands  sw^ell  and  are  sensitive,  even  on 
the  slightest  touch.  If  we  inspect  the  arm  carefully,  we  find  red  striae, 
especially  on  the  flexor  side,  running  longitudinally  from  the  wound 
toward  the  glands  ;  these  reddened  portions  of  skin  are  very  sensi- 
tive. At  the  same  time  there  is  fever,  often  a  coated  tongue,  nausea, 
loss  of  appetite,  and  general  depression.  The  termination  may  be  in 
one  of  two  directions :  under  proper  care  and  treatment,  there  is  gen- 
erally resolution  of  the  inflammation ;  the  strife  gradually  disappear, 
as  do  also  the  swelling  and  pain  of  the  axillary  glands ;  the  fever 
ceases  at  the  same  time.  In  other  cases  there  is  suppuration ;  the 
skin  of  the  arm  reddens  gradually  and  extensively  in  a  few  days  and 
becomes  osderaatous.  The  swelling  of  the  axillary  glands  uicreases, 
the  fever  becomes  greater,  and  there  may  even  be  chills.     In  a  few 


380  ERYSIPELAS  TRAUMATICUM. 

days  fluctuation  occurs  .most  frequently  in  the  axilla,  occasionally  else- 
where in  the  arm,  the  abscess  opens  spontaneously  or  is  incised,  and 
pus,  such  as  is  usually  contained  in  a  circumscribed  abscess,  is  evacu- 
ated.  Then  the  fever  subsides,  as  do  also  the  pain  and  swelling ; 
and  the  patient  speedily  recovers  from  his  disease,  which  is  often  very 
painful  and  troublesome.  Tlie  termination  is  not  always  so  favorable  ; 
but,  in  lymphangitis  from  poisoned  wounds,  pytemia  is  occasionally 
developed,  in  the  subacute  form  most  frequently ;  of  this  more  here- 
after. In  one  case  with  lymphangitis  of  the  leg,  where  the  patient 
had  chronic  inflammation  of  the  kidneys  at  the  same  time,  I  saw  the  in- 
guinal glands  with  the  superjacent  skin  become  gangrenous,  after  they 
had  been  enormously  swollen.  This  termination  is  very  rare,  although 
the  pus  in  these  inflammations  of  the  lymphatic  vessels,  especially 
after  poisoning  with  cadaveric  matter,  is  occasionally  putrid  in  char- 
acter. Acute  inflammation  of  the  lymphatic  glands,  terminating  in 
resolution  or  suppuration,  occurs  as  an  idiopathic  disease ;  in  such 
cases  we  cannot  see  the  connection,  by  red  lines  along  the  lymphatics, 
between  a  wound,  or  another  point  of  inflammation,  and  the  lymphat- 
ic glands ;  this  may  be  because  only  the  superficial  vessels  appear  as 
red  cords  in  tlie  skin,  while  the  deeper  ones,  even  when  inflamed,  are 
not  recognizable  to  the  sight  or  touch.  Hence  in  the  patient  w^e  only 
know  superficial  lymphangitis.  One  of  the  peculiarities  of  this  dis- 
ease is,  that  when  it  occurs  in  the  extremities  it  rarely  extends  be- 
yond the  axillary  or  inguinal  glands.  Once  in  a  case  of  lymphangitis 
of  the  arm  and  adenitis  of  the  axilla  I  saw  pleurisy  occur  on  the 
same  side,  which  possibly  may  have  resulted  from  extension  of  the  in- 
flammation through  the  lymphatic  vessels. 

We  know  very  little  of  the  pathological  anatomy  of  lymphangitis 
of  the  subcutaneous  tissue,  scarcely  more  than  we  can  see  with  the 
naked  eye  on  the  patient,  for  this  disease  is  scarcely  ever  fatal  when 
it  only  attacks  the  lymphatic  vessels,  and  in  animals  it  can  only  be 
very  imperfectly  induced  by  experiment.  The  cellular  tissue  imme- 
diately around  the  lymphatic  vessels  is  decidedly  implicated,  the 
capillaries  dilated  and  distended  -with  blood.  We  cannot  decide 
whether  the  lymphatic  vessel  is  obstructed  in  the  later  stages  by 
coagulating  lymph,  or  whether  coagula  form  in  the  lymph  at  the  start 
and  irritate  the  walls  of  the  vessels.  K  we  may  transfer  the  obser- 
vations on  uterine  lymphangitis,  which  so  often  occurs  in  puerperal 
fever,  to  the  skin,  in  certain  stages  there  is  pure  pus  in  the  dilated 
lymphatic  vessels ;  the  vicinity  of  these  vessels  is  infiltrated  with 
serum  and  plastic  matter;  the  plastic  infiltration  of  the  cellular  tissue 
increases  to  suppurative  infiltration,  or  even  to  formation  of  abscess, 
in  which  the  thin-walled  lymphatic  vessels  themselves  disappear ;  the 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,  ETC.  38I 

finer  the  net-work  of  lymphatic  vessels,  the  more  difficult  it  is  to  dis- 
tinguish lymphangitis  from  inflammation  of  the  cellular  tissue.  From 
the  illustrations  of  Cruveilhier  (Atlas,  Livre  13,  PI.  2  and  3),  we  may 
derive  an  idea  of  puerperal  lymphangitis,  and  carry  this  to  the  same 
affections  in  other  parts.  The  red  striae  that  we  see  in  the  skin  can 
only  be  caused  by  dilatation  of  the  blood-vessels  around  the  lymphatics, 
not  by  blood  forcing  its  way  into  the  latter ;  hence  in  patients  we 
really  see  the  symptoms  of  perilymphangitis  induced  by  contact  with 
the  poison  streaming  in  the  lymphatic  vessels.  We  know  the  changes 
in  the  lymphatic  glands  rather  better.  In  them  the  vessels  are 
much  distended,  and  the  whole  tissue  greatly  infiltrated  with  serum ; 
quantities  of  cells  fill  the  alveoli  tensely,  which  probably  at  first  im- 
pedes and  finally  arrests  altogether  the  movement  of  the  lymph  in  the 
gland ;  this  blocking  up  of  the  gland  will  to  some  extent  prevent  the 
extension  of  the  morbid  process. 

Lymphangitis  may  occur  in  any  wound  or  point  of  inflamma- 
tion ;  but  in  my  opinion  ih  is  always  the  result  of  irrritation  from  a 
poison  passing  through  the  lymphatic  vessels.  The  nature  of  this 
poison  may  vary ;  it  may  be  decomposed  secretion  from  a  wound, 
putrid  matters  of  all  sorts  (especially  that  from  the  cadaver),  or 
matters  which  from  excessive  irritation  form  an  inflamed  point.  We 
have  already  stated  that  the  friction  from  a  boot-nail  may  excite  a 
simple  excoriation  into  a  difi'use  inflammation,  in  which  a  (phlogistic) 
poison  may  and  often  does  form,  and  excites  lymphangitis ;  the  same 
thing  occurs  in  points  of  inflammation  from  other  causes  ;  by  increased 
initation  a  material  is  formed  in  the  inflammatory  focus  itself,  which 
proves  very  irritant  to  the  lymphatic  vessels  and  their  surroundings ; 
even  a  poison  encapsulated  in  an  inflamed  part  may  by  increased 
pressure  of  the  blood  be  driven  into  the  lymphatic  vessels,  and 
thence  into  the  blood,  although  without  this  cause  it  might  have 
remained  quiet,  and  been  gradually  thrown  off  or  eliminated  by  sup- 
puration. The  following  case  may  serve  as  an  illustration :  One  of 
my  colleagues  had  a  slight  inflammation  on  the  finger,  from  a  dis- 
secting wound ;  this  inflammation  was  purely  local,  scarcely  observ- 
able ;  on  a  short  trip  in  the  Alps  he  became  heated,  in  the  evening 
he  had  a  lymphangitis  of  the  arm  and  high  fever ;  the  active  move- 
ment and  consequently  increased  action  of  the  heart  had  driven  the 
poison,  previously  lying  quiet  in  the  circumscribed  point  of  inflamma- 
tion, through  the  lymphatic  vessels  into  the  blood. 

[Still  more  peculiar  are  the  cases  where  a  lymphangitis  starts 
from  a  part  which  has  been  inflamed  and  recovered  ;  we*  must 
assume  that  in  such  a  cicatrix,  as  in  the  lymphatic  glands,  a  poison- 
ous substance  may  remain  latent  for  a  time,  and  then  from  some 


382  ERYSIPELAS  TRAUMATICUM. 

irritation,  or  from  a  greater  flow  of  blood  (from  exercise,  overheat- 
ino-,  etc.),  the  poison  is  carried  into  tlie  circulation,  and  we  have 
acute  lymphangitis,  often  accompanied  by  severe  phlegmonous  in- 
flammation. 

Hence  it  is  proper  when  patients  have  suffered  from  local  sup- 
puration, especially  if  caused  by  infection,  even  after  it  has  healed, 
for  them  to  avoid  for  a  long  time  all  muscular  strain,  heating,  or 
anything  that  may  hasten  circulation  of  the  blood  or  lymph.] 

Why,  in  the  different  cases,  we  have  sometimes  diffuse  phleg- 
monous inflammation,  sometimes  erysipelas  or  lymphangitis,  cannot 
be  certainly  stated,  though  it  may  be  due  to  purely  local  causes, 
and  to  the  character  of  the  poison. 

[Some  surgeons  regard  erysipelas,  lymphangitis,  progressive 
phlegmon,  acute  septic  cedema,  and  the  analogous  inflammations  of 
internal  organs,  as  identical ;  Virchoio  was  of  this  opinion,  and  the 
same  view  is  now  held  by  TUlmanns.  But,  in  spite  of  their  occur- 
ring in  combination,  I  would  regard  them  as  clinically  distinct,  and 
when  they  occur  together  one  may  recede  as  the  other  advances. 
Local  perilymphangitis  may  possibly  be  due  to  pus-cells  from  some 
point  of  inflammation  escaping  through  the  IjTnphatic  vessels.] 

From  our  present  knowledge  of  the  passage  of  cells  out  of  the 
vessels  we  may  imagine  that  pus-cells  developed  in  the  wound  thence 
pass  into  the  lymphatic  vessels,  wander  through  the  walls  of  these 
vessels,  and  as  bearers  of  an  irritating  substance  excite  perilym- 
phangitis, while  the  cells,  flowing  more  rapidly  in  the  centre  of  the 
vessel,  enter  the  blood,  and  thus  perhaps  induce  fever  before  the 
local  disease  has  attained  any  considerable  extent. 

The  object  of  treatment  in  recent  cases  of  lymphangitis  is  to 
obtain  resolution  if  possible,  and  to  prevent  suppuration.  The 
patient  should  keep  the  affected  limb  as  quiet  as  possible ;  should 
there  be  gastric  derangement,  an  emetic  is  very  beneficial.  The 
disease  not  unfrequently  subsides  after  the  purgation  and  sweating 
induced  by  the  emetic.  Among  the  local  remedies,  rubbing  the 
whole  limb  with  mercurial  ointment  is  particularly  efiicacious  ;  then 
the  part  should  be  covered  warmly  so  as  to  maintain  an  elevated, 
regular  temperature.  For  this  purpose  we  may  employ  wadding 
or  moist  warmth.  Should  the  inflammation  increase  in  spite  of  this 
treatment,  and  diffuse  redness  and  swelling  occur,  suppuration  will 
take  place  at  some  spot.  This  diffuse  inflammation  is  no  longer 
limited  to  the  lymphatic  vessels,  but  the  entire  subcutaneous  tissue 
participates  in  it  more  or  less.  As  soon  as  fluctuation  is  distinctly 
perceived,  an  opening  should  be  made,  and  the  pus  evacuated. 
Should  healing  be  retarded,  it  may  be  hastened  by  daily  warm 


TRAUMATIC   AND   IXFLAMMATORY   DISEASES,  ETC.  383 

baths  ;  these  are  particularly  useful  where  there  is  a  great  tendency 
for  the  disease  to  return  to  a  spot  once  attacked.  A  septic  poison 
encapsulated  in  the  lymphatic  glands,  if  forced  into  the  circulation 
by  fluxion  to  the  glands,  may  induce  new  lymphangitis  and  phleg- 
monous periadenitis ;  this  explains  the  repeated  relapses,  and  the 
latency  of  the  disease  after  infection,  especially  in  dissecting  wounds. 

[When  speaking  of  injuries  it  was  stated  that  the  injury  itself 
caused  no  inflammation,  but  that  some  complication  must  be  super- 
added to  excite  traumatic  inflammation  ;  the  most  frequent  of  these 
complications  have  also  been  described.  Strictly  speaking,  inflam- 
mation after  injuries  is  an  accidental  traumatic  disease,  standing 
between  so-called  normal  traumatic  inflammation  and  accidental 
traumatic  diseases.  But  it  is  customary  to  regard  those  cases  of 
inflammation  following  an  injury  as  noi-mal  if  the  local  symptoms 
remain  limited  to  the  injured  parts.  This  view  is  doubtless  be- 
cause in  the  great  majority  of  cases  left  to  themselves,  some  irrita- 
tion always  occurs,  not  from  the  injury,  but  from  necessary  com- 
plications. When,  in  following  chapters,  we  treat  of  accidental 
traumatic  diseases,  we  do  not  mean  so-called  traumatic  inflamm.a- 
tion.  I  must  now  inform  you  that  occasionally  other  peculiar  in- 
flammatory and  gangrenous  processes  affect  the  wound,  and  may 
induce  severe  and  usually  feverish  constitutional  diseases  ;  some 
of  these  may  also  come  without  anything  unusual  having  been 
noticed  about  the  wound.  Lastly,  in  an  existing  wound,  or  at  the 
time  of  its  reception,  as  in  a  bite  from  a  poisonous  or  diseased 
animal,  substances  may  enter  that  may  cause  local  inflammation  or 
general  blood-poisoning.  Of  these  we  shall  now  treat,  and  will 
first  speak  of  the  local  symptoms  that  may  accompany  a  point  of 
inflammation. 

Recent  wounds  may  be  infected  by  decomposing  secretion  en- 
tering the  open  spaces  of  the  tissue,  or  by  infected  objects,  such  as 
unclean  sponges  ;  these  contain  vegetations  or  germs  of  micrococci, 
which,  being  introduced  into  the  wound,  there  find  conditions  favor- 
able for  their  development,  and  spread  ;  and,  wherever  they  reach, 
induce  progressive  inflammations. 

Among  the  differences  between  diphtheria  of  wounds  and  hos- 
pital gangrene  are  the  progressive  pulpous  destruction  of  the  edges 
of  the  wounds  in  the  former,  the  great  sensitiveness  of  the  granu- 
lations, and  their  tendency  to  bleed.  But  I  believe,  with  Heine, 
who  has  written  an  excellent  monograph  on  hospital  gangrene,  that 
the  variations  in  the  course  of  this  and  diphtheria  of  wounds  is  not 
due  to  any  essential  conditions.    There  are  various  grades  of  wound 


384  ERYSIPELAS  TRAUMATICUM. 

diphtheria,  whose  common  sign  is  infiltration  of  the  granulations  by 
rapidly-hardening  exudation,  which  is  at  once  followed  by  its  gan- 
grene. Sometimes  the  diphtheritic  infiltration  affects  at  the  same 
time  the  surface  and  edges  of  the  wound,  and  progresses  so  rapidly 
as  to  destroy  a  considerable  layer  of  tissue  in  a  few  hours.  This 
forms  the  pulp  that  may  be  rubbed  off,  thereby  exj)osing  bleeding, 
ragged,  deep  tissues.  Heine  has  claimed  that  hospital  gangrene 
may  result  from  infecting  wounds  with  the  virus  of  true  diphtheria 
of  mucous  membranes,  and  that  he  has  seen  patients  attacked  with 
pharyngeal  diphtheria  after  exposure  to  hospital  gangrene.  More- 
over, the  paralyses  peculiar  to  diphtheria  are  said  to  accompany 
hospital  gangrene.  It  seems  as  if  both  diseases  were  especially 
malignant  in  certain  epidemics. 

The  most  important  treatment  for  diphtheria  of  wounds  is  pro- 
phylactic, and  consists  chiefly  in  the  ap])lication  of  Lhter''s  dressing 
whenever  possible,  and  closely  watching  insignificant  injuries  which 
cause  infection  because  they  are  not  cared  for. 

For  local  application,  a  most  excellent  remedy  is  iodoform  ;  the 
diseased  tissue  may  be  scraped  out,  and  the  powder  freely  applied. 
It  is  esjjecially  useful  in  cases  where  the  mouth  is  affected,  or  where 
operations  have  been  done  on  the  jaws. 

The  sensitiveness  to  pain  of  the  reddened  slcin  gives  a  tolerably 
certain  diagnostic  symptom  for  distinguishing  erysipelas  from  sim- 
ple erythema,  or  from  so-called  pseudo-erysipelas  or  phlegmonous 
inflammation.  In  erysi])elas,  light  pressure  or  stroking  the  reddened 
skin  with  the  finger  is  painful,  while  it  is  not  so  in  erythema  ;  and 
in  phlegmon,  hard  pressure  causes  a  dull,  deep  pain. 

On  carefully  examining  patients  with  so-called  spontaneous  or 
non-traumatic  erysipelas,  you  may  almost  always  find  a  small  skin- 
wound,  or,  in  old  persons  with  erysipelas  about  the  nose,  there  may 
be  an  abscess  about  a  hair-follicle  in  the  nostril ;  there  will  prob- 
ably be  some  sore  of  which  the  patient  was  unconscious.  As  these 
points  are  often  scratched  with  dirty  finger-nails,  they  might  very 
easily  be  infected.  Hence,  undoubtedly,  most  so-called  spontaneous 
cases  of  erysipelas  are  truly  traumatic.  Tillmanns's  inoculations 
of  rabbits  seem  to  have  induced  true  erysipelas,  as  shown  by  the 
temperature  and  examination  of  the  animals  exiDcrimented  on.  He 
observed  that  the  presence  of  coccus  vegetations  was  not  essential 
for  the  erysipelatous  process  ;  also  that  the  transfer  of  erysipelas 
by  subcutaneous  injection  of  serum  from  erysipelas  vesicles  was 
possible,  but  did  not  always  succeed  ;  and,  lastly,  in  successful  in- 
oculations, the  fluid  always  contained  cocci,  although  fluid  contain- 
ing them  did  not  always  cause  erysipelas.     His  exj)eriments  show 


TRAUILVTIC   AND   INFLAMMATORY  DISEASES,  ETC.  385 

that  there  may  be  erysipelas  with  or  witliout  fungi,  and  that  the 
poison  may  be  transferred  by  fluid  with  or  without  cocci.  Accord- 
ing to  his  views,  erysipelas  poison  may  also  enter  the  body  by  solu- 
tions of  continuity  of  the  respiratory  or  digestive  tracts. 

In  the  treatment  of  erysipelas,  Ilueter  recommended  very  highly 
subcutaneous  injections  of  two-per-cent.  solution  of  carbolic  acid, 
but  they  are  only  of  use  at  the  very  onset ;  a  Pravaz^s  syringe- 
ful  of  the  solution  is  scarcely  enough  for  a  space  half  as  large  as  a 
card. 

Internally,  patients  stand  lai'ge  amounts  of  stimulants,  and  they 
should  have  good,  easily-digested  food.] 

26 


386 


PHLEBITIS, 


LECTURE    XXV. 

5.  Phlebitis ;  Thrombosis  ;  Embolism. — Causes  of  Venous  Thrombosis  ;  Various  Meta- 
morphoses of  the  Thrombus. — Embolism. — Ked  Infarction,  Embolic  Metastatic  Ab- 
scesses.— Treatment. 


5.  Phlebitis;  Thrombosis;  Embolism;  Embolic  3fetastatic  Ab- 
scesses.— Besides  the  above  forms  of  inflammation,  there  is  often 
another  phlebitis  and  thrombosis,  which,  starting  from  a  wound  or 
point  of  inflammation,  is  at  first  local,  but  afterward  spreads  in  a 
peculiar  manner  to  several  organs.  In  persons  djnng  from  this  dis- 
ease we  find  pus,  or  friable,  purulent,  or  putrid  clots,  in  the  thick- 
ened or  partly-supi^urating  veins  near  the  injured  part.  Often, 
also,  there  are  abscesses  in  the  lungs,  more  rarely  in  the  liver,  spleen, 
and  kidneys.  Cruveilhicr  proved  that  these  metastatic  abscesses 
were  connected  with  the  pus  in  the  veins  ;  but  the  mode  of  this 
connection  was  not  explained  till  subsequently. 

What  I  shall  tell  you  to-day  on  this  subject  is  the  result  of  nu- 
merous investigations  and  experiments,  for  which  we  are  indebted 
to  Virchoto,  and  which  have  been  so  often  repeated  and  confirmed 
by  different  ])ersons  that  there  can  be  no  doubt  of  their  correct- 
ness ;  I  have  myself  studied  the  subject  a  good  deal,  and  shall  at 
the  proper  places  state  where  I  have  arrived  at  different  results.  It 
would  lead  me  too  far  to  follow  this  great  work  of  Virchow  histor- 
ically, and  to  give  you  an  epitome  of  it ;  I  must  leave  it  to  your 
own  industry  to  study  these  works,  and  content  myself  with  giving 
you  a  short  resume  of  the  positive  results. 

The  first  important  question  is,  What  is  the  relation  of  the  co- 
agidation  of  the  blood  to  the  inflammation  of  the  vessel?  The 
former  view,  that  the  coagulation  is  due  to  the  inflammation  of  the 
wall  of  the  vessel,  is  purely  hypothetical,  and  not  susceptible  of 
proof.  On  the  contrary,  we  know  from  the  investigations  as  to 
the  formation  of  thrombus  after  ligation  of  arteries,  and  of  the 
process  of  healing  of  injured  veins,  that  there  is  immediate  coagu- 
lation of  blood  in  the  injured  vessel,  before  there  can  be  any  in- 
flammation of  the  walls  of  the  vessel.  The  blood-clot  forming  in 
veins  after  their  injury,  and  constituting  their  thrombus,  is  usually 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC.  387 

short,  it  is  true,  but  we  may  readily  imagine  that  it  should  increase 
in  size  from  continued  deposits  of  fibrine.  You  know,  from  your 
studies  in  physiology,  that  we  cause  coagulation  of  the  fibrine  by 
whipping  the  blood.  During  the  motion  of  the  blood  the  coagu- 
lating fibrine  deposits  like  crystals  on  a  rough  body,  and  you  can 
readily  satisfy  yourselves  experimentally  that  such  a  body,  as  a  cot- 
ton thread,  introduced  into  the  vein  of  a  living  animal,  soon  be- 
comes covered  with  fibrine.  Thus  roughnesses  of  vai'ious  kinds  in 
the  vessels  may  give  rise  to  more  or  less  extensive  coagulations  of 
the  blood.  These  roughnesses  may  certainly  form  on  the  inner 
wall  of  the  vein  as  a  result  of  inflammation,  and  coagulation  of  the 
blood  may  thus  be  induced.  Projections  into  the  calibre  of  the 
veins  may  be  caused  by  small  abscesses  in  the  walls  ;  formerly,  it 
was  supposed  that  there  was  a  fibrinous  coagulation  on  the  inner 
surface  of  the  inflamed  vein,  as  on  an  inflamed  pleura  ;  it  can 
scarcely  be  decided  whether  this  really  occurs  ;  what  was  formerly 
considered  as  such  has  been  found  to  be  a  discolored  peripheral 
layer  of  the  blood-clot. 

Besides  the  mechanical  cause  of  the  compression,  which  favors 
coagulation,  in  inflanimation  of  any  tissue  there  is  another  factor 
having  the  same  effect,  namely,  the  changes  In  the  intima  of  the 
vessels,  especially  of  the  veins.  If  we  do  not  know  the  positive 
chemical  conditions  under  which  the  blood  in  the  vessels  must  coag- 
ulate, since  the  classical  investigations  of  Urache  we  do  know  that 
the  normal  living  intima  of  the  vessels  has  the  special  property  of 
keeping  the  blood  fluid,  and  that  coagulation  occurs  when  the  in- 
tima loses  its  normal  qualities.  But  in  the  veins,  as  in  the  capillary 
Avails,  it  loses  its  normal  qualities  through  inflammation,  as  is  shown 
by  the  more  recent  investigations  (.see  Lecture  XXII.)  ;  these  show, 
indeed,  that  the  inflammatory  alteration  of  the  walls  of  the  vessel 
does  not  of  itself  at  first  induce  either  complete  stasis  or  thrombo- 
sis ;  however,  it  is  not  improbable  that  the  latter  is  at  least  fa- 
vored by  the  alteration  of  the  walls  of  the  vessel.  Hence,  the  recent 
views  on  inflammation  would,  in  some  cases  at  least,  confirm  the 
old  view  that  inflammation  of  the  walls  of  the  veins  may  cause 
thrombosis  (even  Avithout  leading  to  abscess  in  their  Avails)  ;  but 
further  investigations  in  this  direction  are  desirable.  Clinical  ob- 
servations also  speak  in  favor  of  such  a  course  ;  for  it  has  been 
proved  that  periphlebitis  (analogous  to  perilymphangitis)  often  pre- 
cedes phlebitis  and  thrombosis. 

At  all  events,  inflanimation  of  the  walls  of  the  vessel  does  not 
always  cause  the  coagulation  ;  much  more  frequently  the  clot 
forming   in  a  vessel   after   injury,    under  certain  not   accurately- 


388  THROMBOSIS. 

known  circumstances,  forms  the  starting-point  for  further  coagu- 
lation, and  finally  for  inflammation  of  the  wall  of  the  vessel.  Besides 
injuries,  there  is  a  second  factor  from  which  coagulations  may  result, 
viz.,  from  retardation  of  the  current  of  the  blood  from  friction,  as  in 
contraction  of  the  vessel ;  this  variety  may  be  called  tJiromhus  from 
compression.  It  also  is  independent  of  inflammation  of  the  vrall  of 
the  vein,  but  may  result  from  inflammation  of  the  perivenous  tissue ; 
for  in  severe  inflammation  a  tissue,  especially  when  it  is  under  the 
pressure  of  a  fascia,  niay  swell  so  much,  partly  from  serous,  partly 
from  plastic  infiltration,  that  the  vessels  -will  be  compressed,  and  stasis 
and  coagulation  of  the  blood  be  thus  induced.  These  thrombi,  from 
compression  in  very  acute  inflammation,  and  especially  in  acute  acci- 
dental inflammation  of  cellular  tissue  around  wounds,  are  more  frequeiit 
than  primary  traumatic  thrombi ;  it  is  the  most  dangerous  variety 
of  thrombus,  as  it  is  most  liable  to  puriform  deliquescence.  In  rapid 
dilatation  of  a  vessel,  also,  according  to  physical  laws,  the  current  of 
blood  is  much  retarded ;  then  coagulation  takes  place  at  the  point  of 
dilatation,  as  we  shall  hereafter  see  iu  aneurisms  and  varices ;  these  are 
called  thrombi  from  dilatation.  Furthermore,  the  current  of  blood 
may  be  retarded  from  insufficient  contraction  of  the  heart  and  arte- 
ries ;  as  this  occurs  chiefly  in  persons  debilitated  by  age  or  severe  ex- 
hausting diseases,  it  is  called  m,arasmic  thrombus.  This,  also,  is  evi-- 
dently  independent  of  inflammation  of  the  veins,  and  occurs  most  fre- 
quently in  parts  distant  from  the  heart. 

You  must  remember  that  in  all  these  cases  the  thrombi  are  at  first 
small,  and  gradually  grow  from  deposit  of  more  fibriue.  It  has  not 
been  proved  that,  in  cases  where  the  thrombus  attains  a  considerable 
extent,  there  is  any  abnormal  increase  of  fibrine  in  the  blood,  although 
this  might  be  supposed.  TFAy  traumatic  thrombi  should  extend  so 
far  in  some  cases  of  injuries  of  the  veins,  we  can  only  understand  in 
cases  Avhere  extensive  ruptures  of  the  veins  are  caused  by  extensive 
contusions,  and  extensive  disturbance  of  the  circulation  is  thus  induced. 
But,  in  cases  where  a  widely-branched  thrombus  results  from  a  punc- 
tured or  incised  wound  of  a  vein  (as  from  venesection),  it  is  often 
difficult  to  explain  the  cause  without  resorting  to  disputed  hyjDotheses. 
Thrombi  fi-om  injury  and  compression,  and  their  sequoias,  particularly 
claim  our  attention,  while  those  from  dilatation  and  marasmus  we  rarely 
meet  in  surgical  cases.  It  has  been  observed  that  venous  thrombi 
ending  in  suppuration  are  far  more  frequent  in  hospitals  than  in 
private  practice,  and  this  tendency  to  coagulation  of  the  blood  has 
been  referred  to  the  hospital  atmosphere  and  the  miasma  it  contains. 
That  hospital  miasm  (itself  a  very  indefinite  and  very  variable  thing) 
should  directly  induce  coagulation  of  the  blood,  can  neither  be  proved 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,  ETC.  339 

nor  denied.  According  to  my  idea,  the  connection  is  probalily  only 
indirect :  toxic-miasmatic  infection  of  a  wound,  whether  induced  by 
instruments,  dressings,  or  otherwise,  as  previously  stated,  excites  acute 
suppurative  inflammations  around  the  wound,  sometimes  as  ordinary 
cellular  inflammation,  sometimes  as  difi'use  lymphangitis,  etc, ;  thrombi 
from  compression  are  caused  by  these  inflammations,  just  as  happens 
in  acute  phlegmonous  inflammation  outside  of  the  hospital ;  hence  the 
influence  of  miasmatic  poisoning  in  inducing  venous  thrombosis  is  not 
direct,  but  indirect,  acting  through  the  inflammation. 

The  next  question  is,  What  becomes  of  the  blood  coagulated  in  the 
vessels,  and  what  is  its  relation  to  the  wall  of  the  vessel?  From  the 
injuries  of  arteries  and  veins,  we  are  only  acquainted  with  one  meta- 
morphosis of  the  thrombus,  namely,  its  organization  to  connective 
tissue.  In  extensive  venous  thrombi  this  is  a  great  rarity,  and  leads 
of  course  to  complete  obliteration  of  the  vein.  Let  us  take  a  very 
simple  case,  a  venesection  thrombus.  After  a  bleeding,  say  from  the 
median  vein,  from  an  acute  inflammation  of  the  cellular  tissue  there  is 
a  coagulation  of  blood  in  this  vein,  and  also  in  the  cephalic  and  basilic 
veins,  down  to  the  wrist  and  up  to  the  axilla.  From  the  disturbance 
of  the  circulation  thus  caused,  there  is  great  oedema  of  the  whole  arm  ; 
when  this  subsides,  we  may  distinctly  feel  the  subcutaneous  veins  as 
hard  cords.  The  course  may  vary  :  first,  the  aifection  may  possibly 
end  in  resolution — under  timely  treatment  this  is  usual ;  the  patient 
should  be  kept  in  bed,  as  he  is  usually  feverish  ;  the  arm  should  be 
kept  absolutely  quiet,  and  covered  with  a  compress  thickly  coated 
with  mercurial  ointment.  At  the  same  time  we  give  a  purgative,  and, 
if  the  tongue  be  coated,  an  emetic.  Under  this  treatment,  the  swell- 
ing of  the  arm  usually  decreases,  and  the  fever  subsides.  Then  the 
firm  venous  cords  can  be  plainly  felt  ;  in  six  or  eight  days  they  become 
softer,  and  finally  cease  to  be  perceptible.  We  very  rarely  have  the 
chance  to  examine  such  cases  anatomically  in  the  early  stages.  Hence, 
we  cannot  decide  to  what  extent,  if  at  all,  the  walls  of  the  vein  parti- 
cipate in  this  coagulation  of  the  blood  ;  but,  from  the  symptoms  and 
the  examination  of  the  patient,  it  would  appear  that  the  fibrine  coagu- 
lated in  the  vessels  is  gradually  reabsorbed  and  mingles  with  the 
blood  without  injury,  like  other  blood  that  has  been  diff'usely  extrava- 
sated  in  the  tissue.  The  second  termination  of  inflammation  of  the 
arm  after  venesection,  complicating  thrombosis,  is  the  formation  of 
abscess.  The  first  symptoms  are  those  above  described ;  but  then, 
either  in  the  bend  of  the  elbow,  the  arm,  or  the  forearm,  a  more 
circumscribed  inflammatory  tumor  forms ;  this  increases  gradually, 
and  finally  fluctuates  distinctly.  On  incision,  pus  is  evacuated  from  a 
larger  or  smaller  cavity,  the  swelling  of  the  arm  then  graduallv  de 


390  THROMBOSIS. 

creases,  the  abscess  heals,  and  complete  cure  may  result.  Anatomical 
examination  of  these  cases  shows  that  there  has  been  suppurative 
inflammation  in  the  connective  tissue  around  the  vein.  We  also  find 
that  the  coats  of  the  thrombosed  veins  are  greatly  thickened ;  this  is 
to  be  regarded  as  a  result,  not  as  a  cause  of  the  thrombosis.  I  will 
here  add  that  the  diagnosis  of  a  venous  thrombus  cannot  always  be 
made,  from  the  vein  feeling  like  a  hard  cord  ;  for  occasional!}'-  inflam- 
mation in  the  cellular  tissue  around  the  vein  may  extend,  and  cause 
condensation  and  tube-like  thickening  of  the  sheath  of  the  vessel, 
which  may  readily  cause  it  to  be  mistaken  for  thrombus,  though  it 
does  not  necessarily  lead  to  it.  I  have  twice  seen  this  mistake  of 
periphlebitic  cellular  induration  for  thrombus  of  the  saphenous  vein, 
and  I  consider  it  impossible  to  make  a  certain  diagnosis  in  all  cases. 
The  fact  that  such  a  periphlebitis,  which  is  perfectly  analogous  to 
perilymphangitis,  and  in  Avhich  the  walls  of  the  veins  certainly  parti- 
cipate, can  exist  without  thrombosis,  proves  beyond  a  doubt  that  the 
latter  is  not  necessarilj'-  the  cause  of  inflammation  of  the  veins,  as  was 
formerly  supposed.  Another  possible  metamorphosis  of  thrombus  is 
friable  disintegration.  In  this,  softening  of  the  clot  usually  begins  at 
the  point  where  the  thrombus  began,  that  is,  at  the  oldest  pai-t.  The 
fibrine  breaks  down  into  a  pulp,  Avhich  is  yelloAvish  or  brownish,  and 
smeary  in  proportion  to  the  number  of  red  blood-corpuscles  contained 
in  the  coagukun.  This  disintegration  spreads  more  and  more ;  even 
the  tunica  intima  of  the  vein  does  not  escape,  it  becomes  wrinkled 
and  thickened.  The  thrombus  changes  to  pus,  which  mingles  with 
the  detritus  of  the  fibrine,  while  the  walls  of  the  veins  and  surrounding 
cellular  tissue  are  greatly  thickened ;  occasionally,  although  rarely, 
small  abscesses  form  in  the  walls  of  the  vein.  Hence,  here  the  inflam 
mation  of  the  wall  of  the  vein  is  to  be  regarded  as  tlie  result  of  soft- 
ening of  the  thrombus,  and  the  pus  which  we  then  find  in  the  vein 
does  not  come  from  the  wound  (the  old  idea),  but  forms  in  the  vein 
from  the  blood-clot.  Often,  also,  the  puriforra  fluid  is  only  fluid 
fibrinous  detritus,  while  in  many  cases  good  thick  pus,  with  fully-de- 
veloped corpiiscles,  may  be  found  in  these  veins.  If  the  wound  be 
putrid,  the  fibrinous  detritus  in  the  vein  may  also  assume  a  putrid 
character,  putrid  fluid  being  taken  up  by  capillary  action  of  the  throm- 
bus from  the  wound  and  acting  as  a  ferment  on  the  disintegrated 
fibrine.  This  capillary  action  of  the  thrombus  might  also  be  supposed 
to  cause  an  action  of  the  decomposed  secretion  on  the  blood.  Of  course 
there  can  be  no  extensive  flow  of  pus  or  other  secretion  from  the 
wound  into  the  vein,  as  the  oj)ening  in  the  vessel  is  plugged  by  the 
thrombus.  Should  there  be  a  rapid  disintegration  of  the  venous  throm- 
bus from  the  peripheral  to  the  central  ends,  which  is  rare,  there  would 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,  ETC.  391 

at  once  be  venous  hemorrhage,  and  the  formation  of  a  new  thrombus^ 
so  that  even  then  there  could  be  no  entrance  of  the  pus  from  the 
wound  into  the  vein,  or  of  that  from  the  vein  into  the  blood ;  moreover, 
the  pus  forming  and  collected  in  the  vein  is  so  shut  off  by  the  central 
end  of  the  thrombus,  that  it  cannot  mingle  with  the  blood ;  at  least  this 
could  only  happen  if  the  central  end  of  the  thrombus  should  be  entirely 
broken  down,  but  this  probably  happens  very  exceptionally,  for  in 
most  cases  there  are  constantly  new  deposits  of  fibrine,  while  disinte- 
gration  goes  on  from  the  oldest  parts  of  the  thrombus.  You  will  thus 
understand  that  the  entrance  of  pus  into  the  injured  vein  cannot  read- 
ily occur,  but  that,  as  will  be  soon  stated,  the  circumstances  must  be 
very  peculiar  to  render  this  possible.  I  must  here  briefly  interrupt 
the  description,  to  state  that  Virchow  does  not  distinctly  acknowledge 
the  transformation  of  the  thrombus  to  pus ;  I  have  no  doubt  on  this 
point :  if  the  blood-cells  in  the  thrombus  have  the  power  of  increasing 
and  changing  to  tissue,  as  seems  most  probable,  there  is  no  reason 
for  not  referring  to  them  the  formation  of  pus  in  the  thrombus,  just  as 
we  do  to  the  white  cells  wandering  out  of  the  vessels,  for  the  coagii- 
lation  of  the  blood  is  not  firm  enough  to  entirely  prevent  cell-move- 
ment. That  the  thrombus  may  change  to  true  pus  by  division  of  the 
white  blood-cells  does  not  appear  to  me  disproved  ;  we  have  already 
mentioned  that  this  pus,  which  is  usually  encapsulated,  does  not  enter 
the  circulation,  or  does  so  very  rarely,  and  hence  has  no  direct  con- 
nection with  pygemia.  To  resume  my  experiences  of  venous  thrombi, 
and  the  history  of  thrombus,  they  are  to  the  effect  that  most  venous 
thrombi  are  the  result  of  very  acute  inflammation  of  cellular  tissue, 
(especially  under  fasciae,  or  tense  skin,  and  in  bone),  and  that  the 
coagulum  undergoes  the  same  metamorphoses  as  the  inflammatory 
new  formation.  If  the  latter  lead  to  formation  of  tissue,  the  thrombi 
are  also  organized  to  connective  tissue  ;  if  the  inflammation  goes  on 
to  suppuration  or  putrefaction,  the  thrombi  also  suppurate  or  putrefy 
and  break  down.  This  is  the  easier  to  understand,  as  we  know,  from 
Von  MecTcUnghcmseri's  and  Bul>noff''s  investigations,  that  the  cells  from 
the  tissue  may  pass  through  the  walls  of  the  vein  into  the  thrombus. 
The  walls  of  the  vein  have  the  same  fate  as  the  thrombus  and  sur- 
rounding tissue :  they  are  infiltrated  with  plastic  matter,  and  become 
thicker,  or  they  suppurate. 

Thrombus,  with  phlebitis,  may  also  run  its  course  as  a  purely 
local  disease,  as  not  unfrequently  hajDpens  after  venesection,  and 
in  some  other  cases.  Then  there  can  only  be  further  danger  when 
the  thrombus  is  friable,  or  when  there  is  purulent  or  putrid  destruc- 
tion of  the  coagulum.  The  central  end  of  the  thrombus  (as  we 
stated  when  speaking  of  arterial  thrombus)   usuallv  extends  to  the 


392 


THROMBOSIS,    EMBOLISM. 


Fig.  67 


point  where  tlae  next  branch  joins,  and  has  a  conical  end,  which 
projects  a  little  (Fig.  67, «),  and,  if  the  coagulura  loses  its  firmness, 
a  portion  of  the  coagukim  may  be  torn  oif  by  the  current  of  blood, 
and  pass  into  the  circulation  ;  this  passes  into  the  larger  veins,  thence 
into  the  right  heart,  thence  to  the  pulmonar}^  artery,  in  whose 
branches  it  is  finally  arrested  at  some  point  of  bifurcation,  as  its  size 
does  not  allow  it  to  pass  farther.  This  branch  of  the  pulmonary 
artery  is  now  closed  by  a  clot  of  fibrine,  as  by  a  cork,  a  so-called 
embolus  /  the  immediate  consequence  is  a  lack  of  blood  in  the  parts 
of  the  lung  previously  supplied  by  the  plugged 
artery.  This  local  lack  of  blood  (ischasmia  of 
Yirchoio)  does  not  usually  last  long,  but  blood 
enters  the  empty  artery  from  small  collateral 
arteries ;  it  is  true,  blood  may  thus  again  enter 
the  vein,  but  it  comes  from  the  small  collateral 
branches,  and  flows  very  slowly,  and  may  at  last 
stop  altogether,  and  coagulation  extend  back- 
ward through  the  capillaries  even  into  the  throm- 
bosed arterial  branch.  Thus,  as  a  result  of  em- 
bolus in  the  artery,  the  whole  corresponding 
vascular  territory  is  thrombosed ;  there  may  also 
be  ruptures  of  the  vessels,  hasmorrhages  ;  as  the 
arteries  of  the  lungs,  spleen,  and  kidneys,  con- 
stantly divide  into  smaller  branches,  and  thus 
the  vascular  territory  constantly  enlarges  toward 
the  periphery,  and  resembles  a  cone  with  the 
apex  in  the  organ,  so  the  part  in  which  the 
above  coagulation  occurs  must  be  shaped  like  a  Dia'^Tam:  a,  central  end  oi 
wedge  or  cone.  In  pathological  anatomy  these 
coagulations  due  to  embolism  have  been  called 
"  red  or  hfemorrhagic  wedge-shaped  infarctions." 
Frequently  as  these  wedge-shaped  infarctions 
occur,  they  are  not  a  necessary  result  of  embo- 

Usm  ;  for,  when  the  arterial  collateral  circulation  is  strong  enough 
in  the  ischemic  part  to  drive  the  blood  through  the  capillaries, 
as  is  the  case  in  otherwise  healthy  persons  and  in  animals,  as  well 
as  in  emboli  causing  little  mechanical  or  chemical  irritation  of  the 
tissue,  there  is  no  infarction,  at  all  events  no  considerable  dis- 
turbance of  circulation,  but  we  have  simply  to  consider  tlie  local 
processes  around  the  embolus,  as  foreign  bodies  in  the  branch 
of  the  artery.  These  local  processes  depend  on  the  character  of 
the  embolus ;  if  the  latter  be  a  pure  fibrinous  clot,  there  is  a  sliglit 
thickening  of  the  wall  of  the  vessel  at  the  point  where  the  embolus  is 


a  venous  thrombus  pro- 
jecting into  a  larjje 
trunk;  6, a  branch  with- 
out thrombus  ;  the  blood 
flowing  through  it  may 
detach  and  carry  into  the 
circulation  the  end  of 
the  thrombus  a. 


TRAUMATIC  AND   IXFLAMMATORY   DISEASES,  ETC.  393 

located  (usually  where  the  artery  divides  into  smaller  branches),  and 
the  latter  may  have  new  clots  deposited  around  it,  and  be  organized 
to  connective  tissue,  or  be  reabsorbed.  Sliould  the  embolus  consist  of 
a  fibrinous  clot  impregnated  with  pus  or  putrid  matter,  it  excites  sup- 
purative or  putrefactive  inflammation,  not  only  in  the  wall  of  the  ves- 
Bel,  but  also  in  the  parts  around.  The  metamorphosis  of  the  red  infarc- 
tion in  part  depends  on  its  size,  partly  on  the  grade  of  the  circulation 
still  continuing  in  parts  of  it,  and  partly  on  the  embolus  causing  the 
trouble.  If  the  latter  be  innocuous  and  the  infarction  be  small,  or  if 
it  be  still  nourished  by  some  vessels  not  thrombosed,  the  coagulum 
forming  the  infarction  may  again  be  dissolved,  or  else  become  organ- 
ized to  a  connective-tissue  cicatrix.  If  the  embolus  be  innocuous,  but 
the  thrombus  extending  completely  through  the  whole  infarction,  the 
tissue  and  coagulum  slowly  disintegrate  to  a  yellow,  granular,  dry 
pulp,  which  becomes  encapsulated,  and  may  calcify ;  this  is  yellow 
dry  infarction.  If  the  embolus  be  impregnated  with  putrid  matter  or 
pus,  it  excites  putrid  or  suppurative  inflammation  all  about  it ;  the  in- 
farction also  becomes  putrid  or  purulent,  and  abscesses  form.  As  we 
were  just  speaking  of  the  lungs,  we  may  here  mention  that  these  ab- 
scesses, which  are  usually  peripheral,  often  excite  plem-isy ;  that  they 
are  most  frequently  multiple  in  both  lungs,  and  may  even  induce  sup- 
puration of  the  pulmonary  pleura  over  the  abscess,  and  may  thus 
occasionally  cause  pneumothorax. 

You  can  hardly  imagine,  gentlemen,  what  labor  it  costs  to  demon- 
strate this  connection  between  venous  thrombi  and  abscess  of  the 
lung,  so  that  I  can  here  announce  it  to  you  as  a  simple  fact.  You 
will  read  the  classical  works  of  Virchoio,  Panum,  0.  Weher^  and 
others,  on  this  subject,  with  astonishment ;  it  would  take  too  long  for 
me  to  enter  into  the  subject  more  fully ;  we  shall  here  assume  the 
right  of  only  taking  the  facts  from  these  Avorks.  We  now  imderstand 
lung  infarctions  and  abscesses ;  but  how  is  it  with  those  that  occur 
under  like  circumstances,  although  much  more  rarely,  in  the  liver, 
spleen,  kidneys,  and  muscles  ;  are  these  also  always  dependent  on 
emboli  ?  A  few  years  since  we  could  not  have  answered  this  ques- 
tion with  certainty ;  now  we  may  affirm  it.  From  experimental  in- 
vestigations, especially  those  of  0.  Weber,  it  is  established  that  cer- 
tain forms  of  emboli,  especially  flocculi  of  pus,  pass  the  pulmonary 
capillaries  without  difficulty,  may  enter  the  left  heart,  and  thence  the 
systemic  circulation,  and  be  arrested  in  the  spleen,  liver,  kidneys,  or 
elsewhere,  and  cause  abscesses.  This  explains  the  rare  cases  where, 
with  venous  thrombus,  there  are  no  abscesses  in  the  lungs,  while  they 
exist  in  other  organs.  If,  with  abscesses  in  the  lungs,  there  are  em- 
bolic infarctions  or  abscesses  in  part  supplied  by  the  systemic  circula- 
tion, they  may  be    attributed  to   the  formation  of  venous   thrombi 


394  THROMBOSIS,  EMBOLISM. 

tlirougli  the  pulmonary  abscess;  portions  from  these  thrombi  pass  into 
the  left  heart,  and  thence  farther.  As  regards  liver-abscesses,  Busch  has 
observed  that  retrograde  movements  of  the  blood  from  the  right  heart 
take  place  in  the  vena  cava,  and  in  this  way  hepatic  emboli  may  occur. 

The  embolic  origin  of  metastatic  abscesses  is  now  so  undoubted 
that,  from  the  existence  of  one  of  these,  we  decide  certainly  on  a 
venous  thrombus  undergoing  putrid  or  suppurative  liquefaction.  The 
discovery  of  the  connection  may  be  easy  in  some  cases,  very  difficult 
in  others :  very  easy  in  cases  of  thrombus  of  large  venous  trunks,  and 
embolism  of  branches  of  the  pulmonary  artery  that  may  be  readily 
reached  with  the  scissors ;  very  difficult  where  there  is  simply  coagu- 
lation in  some  small  venous  net-work  (as  in  phlegmonous  inflammation 
or  decubitus)  and  embolism  of  capillaries  of  the  lungs,  spleen,  kidneys, 
liver,  muscles,  etc. ;  still,  these  latter  cases  are  almost  innumerable. 
On  favorable  objects  (as  in  cerebral  capillaries)  it  has  been  proved, 
beyond  a  doubt,  that  capillary  emboli  exist  in  some  cases ;  it  is  also 
certain  that  small  veins  become  thrombosed  in  all  suppurative  inflam- 
mations ;  it  is  very  difficult,  often  impossible,  to  demonstrate  this 
anatomically  in  every  case.  From  what  symptoms  we  conclude 
whether  a  coagulum  is  old  or  recent,  will  be  taught  you  in  the  lec- 
tures on  pathological  anatomy. 

Then  you  will  also  be  told  how  to  distinguish  small  lobular  infil- 
ti-ations  of  the  lung,  such  as  occui-  in  purulent  bronchitis,  from  me- 
tastatic abscesses.  I  will  merely  mention  here  that  where  a  venous 
thrombus  opens  into  the  Avound,  it  may  remain  firmly  organized 
while  its  upper  part  suppurates,  breaks  down,  and  is  finally  swept 
into  the  circulation  by  the  neighboring  branches  in  which  the  blood 
circulates  ;  this  is  the  only  case  wliere  pus  from  the  veins  enters 
the  circulation  Avithout  there  having  been  haiinorrhage.  After 
death  we  recognize  this  process  by  finding  fluid  blood  or  fresh  post- 
mortem clots  in  the  thickened  veins,  whose  inner  walls  are  rough 
from  adherent  layers  of  the  thrombus  ;  if  there  has  been  periphle- 
bitis, and  the  portion  of  vein  has  suppurated,  we  cannot  decide 
with  absolute  certainty  that  there  has  been  a  previous  suppuration 
of  the  thrombus. 

Here  we  are  only  speaking  of  metastatic  circumscribed  ijiflara- 
mations,  of  infarctions,  and  abscesses  ;  these  alone  are  connected 
with  venous  thi-ombi  and  emboli.  For  diffuse  metastatic  inflam- 
mations another  explanation  must  be  sought ;  we  shall  treat  of  this 
more  under  septicremia  and  pyaemia.  Nor  shall  we  here  discuss  the 
question  of  fever  in  phlebitis  and  in  the  formation  of  metastatic 
abscesses.  As  phlebitis,  ynXh  its  results,  so  very  often  comes  as  an 
addition  to  already-existing  acute  inflammations,  it  is  difiicult  to 


TRAUMATIC   AND    INFLAMMATORY   DISEASES,  ETC.  395 

judge  how  far  it  of  itself  excites  fever ;  metastatic  abscesses,  like 
all  other  points  of  inflammation,  undoubtedly  induce  fever ;  we 
should  scarcely  exiDect  fever  from  a  simple  thrombus  of  the  vessels. 

In  dogs,  by  inducing  numerous  small  emboli  in  the  lungs  by  in- 
jecting flour  or  powdered  coal  into  the  jugular  vein,  we  may,  it  is 
true,  excite  fever,  as  was  shown  by  Bergmann,  Strieker,  and  Albert; 
but  this  does  not  always  occur  in  embolism  in  other  vascular  tracts, 
and  possibly  depends  on  increased  action  of  the  respiratory  muscles. 

The  treatment  of  phlebitis  and  thrombus  is  the  same  as  that  of 
lymphangitis  and  other  similar  acute  inflammations.  Careful  fric- 
tions with  mercurial  ointment,  or,  if  we  fear  detachment  of  the  co- 
agulum,  covering  the  part  with  compresses  smeared  with  mercurial 
ointment,  or  with  bladders  of  ice,  and  absolute  rest  of  the  affected 
part,  are  indicated.  Under  jjysemia  we  shall  speak  of  the  diagnosis 
and  treatment  of  metastatic  abscesses.  If  phlebitis  and  thrombosis 
cause  local  suppuration,  the  abscesses  should  be  opened  as  soon  as 
recognized. 

[As  a  result  of  embolus  there  is  a  faulty  circle,  the  inflammatory 
changes  in  the  walls  of  the  vessels  favor  stasis,  and  this  again  re- 
acts on  the  intima  and  arrests  its  physiological  action.  When  the 
intima  is  altered  it  favors  the  escape  of  red  corpuscles  ;  there  may 
even  be  actual  tears  in  the  vessel,  haemorrhages,  and  on  section  we 
find  the  embolic  foci  not  only  distended,  but  the  whole  tissue  full 
of  blood-corpuscles  and  coloring-matter. 

If  a  thrombus  contain  cocci  and  bacteria,  as  it  does  in  various 
infectious  processes,  fungi  will  develop  in  the  embolic  infarctions 
and  increase  in  the  vessels  and  tissues. 

The  part  of  the  vessel  thrombosed  and  the  tissue  it  supplied  be- 
come necrosed,  the  fluid  part  being  taken  up  by  neighboring  ves- 
sels, and,  as  absence  of  air  and  moisture  prevent  decomposition  of 
the  remainder  of  the  necrosed  part,  it  imdergoes  molecular  disinte- 
gration into  pigment,  cholesterine  crystals,  etc.,  which  remain  en- 
closed in  a  connective-tissue  capsule.] 


396  TRAUMATIC   AND   INFLAMMATORY   DISEASES,  ETC. 


LECTURE    XXVI. 

IT. — General  Accidental  Diseases  which  may  accompany  "Wounds  and  Local  Inflamma- 
tions. 1.  Traumatic  and  Inflammatory  Fever;  2.  Septic  Fever  and  Sopticsemia: 
3.  Suppurative  Fever  and  PyEemia. 

n  -GENERAL  ACCIDENTAL  DISEASES  WHICH   MAY  ACCOMPANY  WOUNDS  AND 
OTHER  LOCAL  INFLAMMATIONS. 

The  local  accidental  traumatic  diseases  which  we  have  so  far  de- 
scribed are  always  accompanied  by  constitutional  disease,  which  is 
chiefly  though  not  always  feverish  in  its  nature.  Fever  is  such  a  com- 
plication of  symptoms  that  it  may  seem  very  different  according  to 
the  addition  of  one  or  other  symptom ;  now  it  is  generally  determined 
only  to  say  that  there  is  fever  when  the  temperature  of  the  blood  is 
elevated,  and  to  measure  the  intensity  of  the  fever  by  the  height  of 
the  temperature,  I  do  not  think  it  advisable  to  combat  this  position, 
for  by  abandoning  it  we  should  lose  the  common  idea  of  what  we  call 
fever,  and  throw  it  back  into  the  old  chaos.  But  I  must  tell  you  that 
there  are  many  and  very  dangerous  general  diseases  in  patients  with 
wounds  or  other  local  inflammations,  in  which  no  change  of  tempera- 
ture of  the  blood  can  be  discovered ;  hence  the  latter  is  only  condi- 
tionally a  measure  of  the  patient's  danger.  Besides  the  elevation  of 
temperature,  in  fever  we  have  the  following  chief  symptoms :  Increased 
rapidity  of  cardiac  action  and  respiration,  loss  of  appetite,  frequently 
nausea,  feeling  of  weakness,  great  sweating,  not  unfrequently  trem- 
bling of  certain  groups  of  muscles  (in  chills),  more  or  less  mental 
excitement  and  blunting  of  the  senses.  Fever  is  a  general  disease, 
which  may  result  from  many  causes ;  in  other  words,  the  number  of 
pyrogenous,  like  that  of  phlogogenous  substances,  is  innumerable. 
According  to  the  quantity  and  quality  of  these  substances  (which  we 
term  poisons)  that  have  entered  the  blood,  one  or  other  set  of  symp- 
toms is  more  prominent :  thus  there  is  fever  with  very  high  tempera- 
ture, while  all  other  symptoms  are  slight ;  fever  with  great  blunting 
of  the  senses,  and  but  Uttle  elevation  of  bodily  temperature ;  fever 
whose  prominent  symptom  is  severe  shivering,  so-called  chills ;  fever 
with  disturbance  of  the  gastric  functions,  fatigue,  etc.,  for  the  chief 
symptoms.  Why,  then,  should  we  not  have  fever  (a  state  of  intoxi- 
cation caused  by  materials  absorbed  from  wounds  or  points  of  inflam- 
mation) with  all  the  symptoms,  except  elevation  of  the  temperature 
of  the  blood  ?  From  some  cause  or  other  this  particular  symptom 
might  in  some  cases  be  concealed  or  prevented  from  appearing.  But, 
as  already  stated,  we  shall  accept  the  present  view  of  fever,  and  only 


TRAUMATIC   AND   INFLAMMATORY  FEVER.  397 

suppose  it  to  exist  where  we  find  elevation  of  temperature  of  the  blood, 
but  must  then  add  that  there  are  cases  of  severe  general,  accidental 
traumatic  and  inflammatory  diseases  which  run  their  course  without 
fever. 

But  there  is  another  common  factor  of  these  general  diseases  that 
we  should  bear  in  mind,  viz.,  that  they  are  all  due  to  reabsorption  of 
matters  that  form  in  the  wounds  or  the  parts  around  them,  or  (what  is 
about  the  same  thing)  in  a  point  of  inflammation.  On  this  point  we 
agree  with  the  present  views,  as  far  as  concerns  traumatic  fever,  in- 
flammator}^  fever,  pycemia,  and  septicemia,  less  so  perhaps  as  regards 
tetanus,  delirium  potatorum,  delirium  nervosum,  and  acute  mania. 
But  many  important  reasons  favor  the  view  of  the  latter  diseases  be- 
ing also  of  humoral  origin ;  hence  I  shall  make  no  further  divisions 
among  the  above  diseases. 

1.  Traumatic  and  Inflammatory  Fever. — It  has  been  already 
explained  (page  98)  that  the  fever  appearing  in  wounded  patients  is 
partly  due  to  the  blood  taking  up  materials  resulting  from  decompo- 
sition of  mortified  tissue  on  the  substance  of  the  wound,  partly  to  the 
absorption  of  materials  formed  by  the  traumatic  or  accidental  inflam- 
mation ;  hence,  in  the  latter  case,  the  nature  of  the  traumatic  and 
inflammatory  fever  is  perfectly  obscure.  On  this  supposition,  which 
we  previously  tried  briefly  to  prove,  it  will  depend  partly  on  the  local 
advantages  for  reabsorption,  partly  on  the  quality  and  quantity  of 
pyrogenous  material  in  question,  how  great  the  poisoning  will  prove. 
There  are  cases  where  the  vessels  opened  by  the  injury  close  so  rap- 
idly, and  the  whole  traumatic  inflammation  terminates  so  quickly,  that 
there  is  no  general  infection  or  fever  at  first,  and  they  may  not  occur 
at  all ;  such  cases  are  rare  in  extensive  injuries,  they  are  the  ideal 
of  the  normal  course ;  in  them  the  plastic  infiltration  on  the  edges  of 
the  wound  leads  quickly  and  throughout  tlie  wound  to  solid  organized 
new  formations,  growing  firmly  in  the  edges  of  the  wound,  and  pass- 
ing on  to  cicatrization  immediately  or  after  precedent  granulation. 
If  we  assume  this  case  as  a  normal  type,  every  traumatic  fever  is  a 
pathological  accident.  We  must  acknoAvledge  this  in  theory,  but  in 
the  great  majority  of  cases,  in  wounds  of  any  size,  fever  occurs  sooner 
or  later ;  hence  we  considered  it  advisable  to  treat  of  traumatic  fever  in 
the  previous  description  of  the  general  condition  of  the  wounded  pa- 
tient. We  have  still,  however,  to  add  something  to  what  was  then 
said,  which  at  that  time  it  would  have  been  difficult  for  you  to  under- 
stand. Let  us  first  speak  of  the  period  at  which  traumatic  fever 
usually  appears,  and  of  its  course.  In  many  cases,  especially  where 
the  injury  has  affected  tissues  previously  healthy,  the  fever  does  not 
begin  till  the  second  day,  increases  rapidly,  and,  with  evening  remis* 


398 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,  ETC. 


sions,  remains  for  some  days  at  a  certain  height,  and  then  ceases 
gradually  (rarely  within  twenty-four  hours).  According  to  my  very 
numerous  observations,  in  far  the  greater  majority  of  cases  the  trau- 
matic fever  begins  within  two  days  after  the  injury.  This  fever  is 
usually  represented  graphically  as  follows  : 

Fig.  68. 


Day  of  the  Disease. 

1. 

2. 

3. 

4. 

J. 

6. 

7. 

s. 

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Fiwr-cnrvc  after  ampntation  of  the  ami.  Recovery.  This  and  the  followinsr  fcvcr-cnrves  r.ro 
ai-raii£:od  on  the  scale  of  Celsius's  thcnnonietcr.  Each  desi-ec  is  divided  iuto  ten  part?;, 
the  horizoiitnl  divisions  indicate  the  day  of  the  disease  ;  the  cun-e  is  mad"  accordinir  to  the 
moruimr  and  evening  measurements ;  the  two  heavy  lines  indicate  the  maximum  aud 
minimum  normal  temperature  of  a  healthy  person. 

The  curve  shows  that,  after  an  amputation  of  the  arm,  rendered 
necessary  by  an  injury  (measurement  was  accidentally  neglected  the 
first  day),  the  fever  did  not  begin  till  the  third  day,  then  continued 
from  the  fourth  to  the  seventh  day ;  after  the  eighth  day  the  patient 
remained  free  from  fever.  In  other  cases,  however,  secondary  fever 
often  occurs  immediately  after  amputation.  Such  an  occurrence  ot 
traumatic  fever  is  quite  frequent,  I  explain  it  as  follows :  Immedi- 
ately after  the  injur}'  the  tissue  of  the  edges  of  the  wound  was  closed 
by  infiltration  of  plastic  matter ;  the  thu'd  day  this  commenced  to 
break  down  into  pus,  and  to  mingle  with  decomposed  shi-eds  of  tissue 
on  the  surface  of  the  wound,  thus  inducing  a  moderately  extensive 
inflammation  of  the  amputation  stump,  with  reabsorption  of  pus  and 
other  products  of  decomposition  and  inflammation  ;  this  reabsorption 
goes  on  till  checked  b}'^  some  mechanical  cause  (diminished  pressure. 


TRAUilATIC  AND   IXFLAMilATORY   FEYEK. 


599 


thickening'  and  partial  closure  of  tlie  vessels,  etc.).  In  other  cases, 
the  fever  begins  the  very  day  of  the  injury ;  we  see  this  when  blood 
has  been  enclosed  between  the  flaps  of  the  united  wound  and  it  has 
rapidly  decomposed;  frequently,  also,  when  operations  have  been 
done  in  tissues  infiltrated  with  the  products  of  chronic  infiltration. 
The  following  case  (Fig.  69)  may  serve  as  an  illustration  of  this 
second  class  : 

Fig.  69. 


Fe^•cn•-cul•ye  after  resection  of  a  carions  wrist,  with   great  iufiltration  of  the   soft  parts. 

Recovery. 

In  infiltration  of  the  tissue  from  chronic  inflammation,  the  finer 
lymphatic  capillaries  may  be  contracted  and  to  some  extent  closed, 
and  hence,  for  some  time,  may  not  have  carried  off  sufficient  serum 
from  the  tissue,  but  the  meditmi-sized  lymphatic  vessels,  hke  the  cor- 
responding veins,  which  in  chronic  inflammation  have  long  been  ex- 
posed to  high  pressure,  are  undoubtedly  distended,  perhaps  even 
gaping,  from  rigidity  of  their  walls ;  hence,  if  not  quickly  filled  "\\'ith 
firm  plastic  infiltration  from  the  start,  they  take  up  a  good  deal  of  the 
secretion  from  the  wound  ;  moreover,  on  the  edges  of  wounds  in  mor- 
bidly-infiltrated tissue,  mortification  is  particularly  apt  to  occur.  This 
explanation  of  the  late  and  early  occurrence  of  traumatic  fever  is 
purely  hypothetical ;  but  it  is  taken  from  and  has  been  induced  by 
numerous  obsers'ations.     It  might  also  be  assumed  that  in  one  case 


400  TRAUMATIC   AND   mFLAMMATORY   DISEASES,  ETC. 

the  ferment  absorbed  into  the  blood  acted  very  slowly,  in  another 
very  quickly ;  nothing  definite  can  be  said  on  this  point.  As  I  for- 
merly believed  that  the  fever  was  alwaj^s  caused  by  nervous  irritation, 
it  w^as  necessary  to  suppose  that  this  irritability  w' as  varied,  and  hence 
the  febrile  effect  might  occur  at  very  different  periods,  but  I  have  en- 
tirely abandoned  this  theory,  without  undervaluing  the  important 
part  played  hy  the  nervous  system  in  the  origin  and  symptoms  of  fever. 

Traumatic  fever  usually  lasts  a  week  ;  it  is  rarely  longer,  without 
some  visible  local  complication. 

When  there  is  an  accidental  inflammation  of  the  cellular  tissue, 
Ij-mphatic  vessels,  or  veins,  about  a  wound,  fever  occurs  simultaneously 
with  this  inflammation,  or  apparently  precedes  it  (coming  as  an  in- 
flammatory secondary  fever,  either  immediately  after  the  traumatic 
fever  or  when  several  or  even  many  days  have  passed  without  fever), 
I  say  it  apparently  precedes,  because  the  first  signs  of  the  local  affec- 
tion may  have  escaped  us,  as  they  may  possibly  have  presented  no 
sensible  symptoms,  or  because  the  poisonous  material  may  have  in- 
fected the  blood  sooner  than  it  did  the  parts  immediately  around ;  the 
probability  of  the  latter  idea  is  based  on  the  fact  that  poison,  taken 
into  the  lymphatic  vessels  or  veins  with  the  lymph  or  blood,  flows  more 
rapidly  in  the  centre  of  the  vessel  than  along  its  walls,  and  thus  quickly 
reaches  the  large  blood-vessels,  while  the  fluid,  moving  more  slowly 
along  the  walls  of  the  vessels,  only  gradually  passes  into  the  perivas- 
cular tissue,  and  there  induces  inflammation  by  the  phlogogenous  poi- 
son it  contains ;  thus  fever  (the  blood-infection)  may  appear  before 
erysipelas,  Ij^mphangitis,  or  phlebitis  (from  the  local  infection),  is  per- 
ceived. The  course  of  this  secondary  fever  entirely  depends  on  that 
of  the  local  inflammation ;  as  the  latter  begins,  the  temperature  rises 
rapidly,  often  with  an  initial  chill.  The  longer  these  secondary  fevers 
continue,  that  is,  the  longer  the  poison  is  kept  up,  the  more  danger- 
ous the  condition  becomes ;  rapid  emaciation,  great  sweating,  sleep- 
lessness, and  continued  loss  of  appetite,  are  bad  symptoms  ;  usually  in 
these  secondary  fevers  there  is  absor])tion  of  pus  or  infection  from 
without.  Pronounced  erysipelas  or  inflammation  of  the  Ij^mphatic 
ressels  or  glands  are  the  relatively  most  favorable  forms  of  the  acci- 
dental inflammations,  as  sooner  or  later  they  generall}'  lead  to  a  certain 
usually  favorable  termination,  and  thus  are  somewhat  typical  in  their 
course,  although  the  duration  of  an  erysipelas  may  vary  from  three 
days  to  three  weeks  or  more,  and  prove  very  debilitating  ;  at  first  the 
fever-curve  rises  rapidly,  then  remains  for  a  time  at  a  certain  height, 
usuall}''  with  morning  remissions  ;  not  unfrequently  the  temperature 
falls  rapidly  ;  the  same  is  true  of  Ijonphangitis.  Fortunately,  it  is  rare 
for  lymphangitis  and  erysipelas  to  extend  deep  into  the  cellular  tis- 
sue and  under  the  fasciae :  in  such  a  case  the  disease  would  be  classed 


TRATJMATIC   AND    INFLAMMATORY    FEVEK. 


401 


among  the  severer  inflammations,  and  would  lose  its  somewhat  tj^pical 
character. 

In  diffuse,  deep  inflammation  of  the  cellular  tissue,  with  or  without 
venous  thrombosis,  the  fever  does  not  begin  so  suddenly,  but,  from  the 
6rst,  always  has  a  decidedly  remittent  type,  and,  like  the  local  affec- 
tions, is  incomputable  in  its  further  course ;  the  loss  of  strength,  the 


ifia.  70. 

Dai/  of  the  Disease,                                       i 

1. 

2. 

3. 

4. 

S. 

6. 

7. 

8. 

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— _ 

Fever-curves  in  erysipeiaB  traamaticum  ambulana  faciei,  capitis  et  colli,  follow  ing  extirpation 
of  a  cancer  of  the  lip.    Recovery. 


emaciation,  sweating,  sensitiveness,  and  excitability  of  the  patient, 
attain  the  highest  grade.  Intermittent  fever  and  metastatic  inflam- 
mations, the  chief  symptoms  of  those  malignant  traumatic  fevers 
which  we  call  "  pyaemia,"  are  greatly  to  be  feared  in  such  cases. 

In  all  these  fevers  the  quantity  of  urea  is  increased  and  exceeds 
the  amount  of  nitrogenous  food  consumed  ;  at  the  same  time,  accord- 
ing to  recent  investigations,  the  weight  of  the  body  diminishes  con- 
siderably. 

As  long  as  the  constitutional  symptoms,  especially  those  due  to 
the  fever,  do  not  extend  beyond  the  above,  and  especially  if  the  dis- 
ease does  not  prove  fatal,  we  are  generally  satisfied  with  the  teriiis 
"  traumatic,  suppurative,  or  secondary  fever."  But,  if  other  symptoms 
occur,  and  death  results,  these  severer  infections  have  two  other 
names,  "  septicaemia  "  and  "  pyemia."    We  follow  this  common  classi' 

fication. 

27 


402  TRAUMATIC  AND   INFLAMMATORY   DISEASES,  ETC. 

2.  Septic  Fever  {Septiccemia). — By  septicaemia,  we  understand  a 
constitutional,  generally  acute  disease,  which  is  due  to  the  absorj)tioi: 
of  various  putrid  substances  into  the  blood,  and  it  is  thought  that 
these  act  as  ferments  in  the  blood,  and  spoil  it  so  that  it  cannot  fulfil 
its  physiological  functions.  This  disease  may  be  induced  in  ani- 
mals by  injecting  putrid  matter  into  their  blood  or  subcutaneous  tis- 
sue, and  it  has  been  found  that  large  animals  (large  dogs,  horses,  etc.) 
may,  under  certain  circumstances,  live  through  the  putrefactive  blood- 
poisoning,  although  it  makes  them  very  sick.  Certain  circumstances 
are  necessary  for  putrid  matter  to  be  taken  into  the  blood  of  man  ; 
such  substances  are  only  taken  through  the  healthy  skin  and  mucous 
membranes  when  the  putrid  substances  have  a  destructive  or  cauter- 
ant  action,  or  an  active  poAver  of  penetrating,  like  fungi  and  infusoria. 
Diseased  skin  or  wound  surfaces  take  up  such  putrid  matters  mqre 
readily,  but  even  they  only  do  so  under  certain  circumstances ;  for 
instance,  they  do  not  readily  pass  through  well-organized,  uninjured 
granulations.  If  we  dress  a  nicely-granulating  wound  on  a  dog  with 
charpie  dipped  in  the  filthiest  putrid  matter,  if  the  latter  contain  no 
cauterant  substance  that  may  destroy  the  granulation  surface,  the  ani- 
mal will  not  sicken,  nothing  will  be  absorbed.  Hence  I  conclude  that 
the  poison  must  in  some  way  be  prevented  from  entering  the  blood- 
vessels in  the  surface  of  the  granulations.  If  the  septic  poison  be  in- 
troduced into  the  fresh  tissue,  it  not  only  excites  severe  local  inflam- 
mation, but  quickly  induces  general  fever.  From  these  peculiar  con- 
ditions under  which  infection  from  putrid  substances  usually  takes 
place,  it  seems  to  me  evident  that  the  poison  is  absorbed  chiefly  by 
the  lymphatic  vessels,  as  I  have  already  mentioned.  Remember,  also, 
that,  in  contused  wounds,  decomposing  shreds  of  firm  connective  tis- 
sue, especially  of  tendons  and  fascice,  often  lie  for  a  long  time  on 
granulating  wounds,  without  any  septic  poison  passing  from  them 
through  the  superficial  vessels  of  the  granulations  into  the  blood  ;  this 
observation  verifies  the  experiments  made  on  dogs.  But,  if  the  poison 
be  not  taken  up  by  the  blood-vessels,  or  be  taken  only  under  certair 
circumstances,  it  is  very  probable  that  its  absorption  is  chiefly  through 
the  lymphatic  vessels.  I  will  not  deny  that  possibly  in  certain  swol- 
len states  of  the  walls  of  the  blood-vessels,  as  well  as  from  capillar}' 
attraction,  and  also  through  the  thrombi  of  the  vessels,  infectious  mate- 
rials may  reach  the  blood,  nor  that  cells  take  up  septic  molecular 
substances  and  may  wander  with  them  into  the  blood-vessels  ;  but,  on 
the  whole,  I  consider  this  mode  of  infection  the  exception,  especially 
if  the  infectious  substance  be  not  dissolved,  but  exist  as  very  fine 
molecules ;  if,  for  instance,  it  be  taken  up  in  the  form  of  dust.  Of  the 
healthy  parts  of  the  body  exposed  to  the  air,  it  has  only  been  proved 


SEPTICEMIA.  403 

that  dust-like  bodies  (as  coal-dust)  enter  the  lungs,  and  may  thence 
reach  the  bronchial  glands  (thence  also  the  blood),  while  a  similar 
absorption  from  the  walls  of  the  intestines  has  not  yet  been  observed 
or  experimentally  proved.  Should  the  miasmata  really  be  small  fungi, 
that  is,  molecular  bodies,  from  what  has  been  said,  it  would  seem  very 
probable  that  the  infection  may  take  place  through  the  respiration ;  if 
this  should  be  proved,  it  might  be  of  great  practical  consequence. 

Of  late,  many  attempts  have  been  made  to  determine  what  sub- 
stance in  decomposing  animal  tissue  is  the  true  poisonous  principle, 
and  for  this  purpose  putrid  fluids  have  been  treated  chemically  till 
Bome  one  body  should  be  found  which  in  the  smallest  dose  should  ex- 
cite the  symptoms  of  septic  poisoning.  Thus  Bergmann  has  produced 
a  body  of  this  nature  from  decomposing  yeast,  which  he  calls  sepsin. 
To  prove  that  this  body  alone  (whose  presence  Fischer  could  not 
prove  in  decomposing  serum  or  pus)  is  the  poison,  it  would  be  neces- 
sary to  prove  the  innocuousness  of  all  other  bodies  chemically  formed 
during  putrefaction.  But  this  cannot  be  done  ;  sulphuretted  hydro- 
gen, sulphuret  of  ammonium,  butyric  acid,  leucin,  and  some  other  sub- 
stances, forming  during  the  putrefaction  of  organic  bodies,  also  act  as 
septic  poisons  when  injected  into  the  blood  ;  so  that  I  cannot  enter 
into  the  laborious  search  for  one  body  in  the  putrid  fluids  which 
shall  bear  all  the  blame  of  the  injurious  effects.  It  is  very  probable 
that  in  decomposing  fluids,  according  to  their  qualities,  degree  of 
concentration,  temperature,  etc.,  very  many  different  poisonous  sub- 
stances may  form,  which  I  further  imagine  as  going  on  changing  till 
they  reach  some  final  terminal  stage. 

Whether  this  terminal  stage  is  always  the  same  is  still  to  be  de- 
termined. This  is  not  the  place  to  discuss  such  difficult  questions 
exhaustively  ;  so  far  as  m}'  experience,  observations,  and  studies  go, 
I  consider  it  at  least  probable  that  the  septic  matters  are  formed  in 
the  inflamed  and  gangrenous  tissues,  and  pass  to  the  blood  as  a  de- 
veloped poison.  Opposed  to  this  view  is  another,  that  only  a  fer- 
ment goes  to  the  blood  from  the  tissues  (ultimately  from  the  air), 
which  soon  causes  fermentation  or  decomposition  [0.  Weber).  Ac- 
cording to  this,  the  absorbed  septic  matters  would  not  be  in  them- 
selves poisonous,  but  would  develop  poison  in  the  blood  from  its 
components. 

[Possibly  the  fever  occurring  in  sensitive  persons  from  constipa- 
tion may  be  due  to  poisonous  matters  being  driven  into  the  absorb- 
ents by  mechanical  pressure.  This  rise  of  temperature  is  rarely 
over  102°,  and  is  usually  only  observed  in  persons  under  treatment, 
possibly  because  they  have  their  temperature  taken  regularly. 
Probably  putrid  gaseous  substances  are  absorbed  from  the  intestinal 


404  TRAUMATIC   AND   INFLAMMATORY   DISEASES,  ETC. 

canal,  where  they  have  been  under  certain  pressure.  The  best 
proof  that  the  sole  cause  of  the  fever  was  the  constipation,  is  the 
immediate  relief  given  by  an  effective  enema.  The  same  cause  may 
account  for  the  fever  in  some  strangulated  hemise  or  acute  obstruc- 
tions of  the  bowels.  If  the  pressure  from  without  exceed  the  in- 
tra-vascular  pressure,  the  decomposing  fluid  may  be  driven  into  the 
vessels. 

If  there  be  cocci  in  the  septic  fluid,  there  must  still  be  certain 
favorable  conditions  to  ensure  their  passing  through  uninjured 
granulations  ;  the  upper  cell  layers  are  constantly  thrown  off  as 
pus,  and  the  pressure  of  the  blood  and  lymphatic  circulation  from 
below  toward  the  surface  interferes  with  absorption. 

Experiments  for  inducing  acute  infectious  osteomyelitis  showed 
that  when  the  medulla  of  bones  had  been  injured,  feeding  the  ani- 
mals on  putrid  substances  sufficed  to  induce  infection  of  the  wound 
of  the  bone  ;  so  poison  must  be  absorbed  from  the  bowels. 

From  decomposing  macerated  meat  Panum  obtained  a  non-al- 
buminous body,  soluble  in  water,  and  also  a  second,  very  poisonous 
substance  ;  Zuelzer  and  Sonnenschein  also  discovered  a  septic  sub- 
stance resembling  the  alkaloids. 

To-day  there  is  little  doubt  that  the  impulse  to  development  of 
the  process  by  which  septic  matters  are  formed,  is  given  by  a  living 
organized  ferment,  micro'organisms  ;  and  it  has  been  shown  that 
other  infectious  processes  may  cause  and  transfer,  by  peculiar  vege- 
tations, a  number  of  acute  and  chronic  diseases.  At  present  the 
views  appear  to  be  about  as  follows  :  Septic  or  putrid  poison  docs 
not  seem  to  depend  exclusively  on  microscopic  organisms,  but  to 
exist  in  solution  in  putrid  fluids.  Non-organized  ferments,  when 
kept  long  at  a  heat  of  1G0°  to  170°,  lose  their  activity,  while  fluids 
containing  cocci  or  bacteria  under  the  same  conditions  retain  their 
septic  powers,  which  are  only  destroyed  by  a  heat  of  2:20°.  If  we 
kill  a  rabbit  by  injecting  fluid  containing  bacteria,  as  Davaine  and 
Strieker  did,  and  inject  some  of  the  blood  of  this  rabbit  into  a 
second  one,  and  of  this  into  a  third  one,  it  remains  fully  as  active 
or  even  more  so  ;  by  breeding  through  several  generations  the  viru- 
lence of  the  virus  increases.  These  inoculations  do  not  change  the 
micro-organisms  morphologically.  Quite  recently  Pasteur  has  made 
the  important  discovery  that,  as  we  may  strengthen  the  virus  by 
cultivating  it  in  various  generations  of  animals,  so  it  may  be  toeak- 
ened  by  cultivating  it  in  a  certain  way  outside  of  the  body.     Pas- 


SEPTICAEMIA.  405 

teur  verified  these  observations  in  so-called  chicken-cholera,  an 
infectious  disease  caused  by  micro-organisms.  He  discovered  the 
very  important  fact  that  animals  which  had  been  inoculated  with 
the  weakened  virus  took  the  disease,  but  did  not  die,  and,  once  hav- 
ing had  the  disease,  were  protected  against  further  inoculation  with 
the  stronger  virus,  which  would  otherwise  be  fatal.  Pasteur  ex- 
plains this  immunity  by  saying  that  the  micro-organisms  destroyed 
or  changed  certain  matters  in  the  body  of  the  animal  so  as  to  leave 
no  proper  nourishment  for  the  development  of  new  micro-organisms. 
Of  course  this  discovery  cannot  be  transferred,  without  further  in- 
vestigation, to  septic  virus. 

Fermentation,  or  the  process  of  breaking  up  organized  bodies 
into  their  original  non-organic  elements,  is  due  to  the  development 
and  evolution  of  organized  beings,  whose  species  differ  with  the 
kind  of  decomposition  or  fermentation.  These  germs  come  from 
without,  and  their  development  may  be  prevented  by  protecting 
the  fermentable  substance  from  contact  Avith  the  air,  or  by  placing 
it  in  air  submitted  to  a  temperature  that  has  destroyed  the  germs 
which  it  always  contains.  Access  of  the  least  particle  of  air  not 
thus  treated  may  induce  fermentation.  It  is  claimed  that,  in  the 
vegetable  kingdom,  diseases  without  exception  are  due  to  parasites  ; 
and  that,  in  the  lower  animals  and  man,  in  all  cases  where  the  eti- 
ology is  known,  the  same  holds  true.  Rabies,  glanders,  syphilis, 
variola,  and  various  skin-diseases,  we  can  transfer  from  one  individ- 
ual to  another  ;  measles,  scarlatina,  whooping-cough,  etc.,  are  con- 
stantly spread  by  contagion.  Constantly  the  proof  seems  augment- 
ing that  this  contagion  is  carried  by  germs.] 

After  these  general  observations,  we  shall  consider  those  surgical 
cases  that  give  rise  to  septic  infection.  First  come  the  cases  where 
there  is  decomposition  on  recent  wounds  ;  it  usually  appears  within 
the  first  three  days  whether  in  such  cases  there  will  be  intense,  un- 
usual, local,  and  general  infection.  If  the  local  infection  merely  evince 
itself  in  moderate  inflammation,  which  soon  leads  to  circumscribed 
suppuration,  if  the  general  infection  be  followed  by  moderate  fever, 
the  affection  would  come  under  the  head  of  traumatic  fever.  But  if 
the  local  infection  be  very  extensive,  with  phlegmonous  inflammation 
and  putrefaction,  and  the  general  condition  assume  a  character  soon 
to  be  described,  we  call  the  state  septicaemia.  In  other  cases  the  re- 
absorption  of  putrid  matter  takes  place  from  a  traumatic  or  idiopathic 
extensive  gangrenous  spot  (as  from  gangrene  due  to  disease  of  the 
arteries)  ;  this  is  more  frequently  the  case  in  moist  than  in  dry  gan- 
grene. In  the  same  way  the  re<|uirements  for  the  reabsorption  of 
putrid  substances  exist,  if  after  delivery  the  placental  surface  of  the 


406 


SEPTICEMIA. 


uterus  becomes  gangrenous ;  some  of  the  cases  of  puerperal  fever  are 
septicasmia. 

It  will  be  evident  to  you  that  the  term  septicaemia  essentially  de- 
pends on  the  etiology,  just  like  the  group  of  "tj^^hous"  diseases; 
and  that  mild  septic-traumatic  fever  has  the  same  relation  to  septi- 
caemia that  typhus  febricula  has  to  typhus;  in  fact,  the  name  "septic 
febricula "  has  been  proposed.  Still,  as  typhus  in  its  different  forms 
is  characterized  by  its  symptomatology  and  pathological  anatomy,  this 
is  also  the  case  in  septicaemia,  although  in  it  the  pathologico-anatomical 
appearances  are  slight.  Now,  what  characterizes  the  course  of  septi- 
caemia? The  nervous  symptoms  deserve  the  first  mention:  the  patients 
are  apathetic  and  sleepy,  if  not  entirely  comatose;  rarely  there  is  fear- 
ful excitement,  and  occasionally  maniacal  delirium ;  at  the  same  time 
the  subjective  feelings  are  good ;  the  patients  do  not  suffer  much.  The 
tongue  is  dry,  often  as  hard  as  wood,  which  renders  the  speech  very 

FiQ.  71. 


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Fever-curve  in  septicaemia  after  extirpation  of  an  immense  lipoma  from  between  the  muBcles 

01'  the  thigh.    Death. 

peculiar;  the  patients  are  thirsty,  but  rarely  drink,  on  account  of  their 
great  apathy.  Not  always,  but  very  frequently,  there  is  profuse  diar- 
rhoea, more  rarely  vomiting.     At  first  there  may  be  great  sweating, 


TRAUMATIC   AXD   INFLAMMATORY   DISEASES,   ETC.  407 

later  the  skin  is  dry  and  flabby.  The  urine  is  scanty,  very  concen- 
trated, and  occasionally  albuminous.  As  the  disense  progresses,  the 
patient  passes  his  urine  and  faeces  in  bed.  Bed-sores  over  the  sacrum 
occur  early.  The  fever  (as  shown  by  the  bodily  temperature)  at  first 
rises  hig-h  ;  in  acute  pure  septiccemia  intercurrent  chills  never  occur 
in  the  course  of  the  disease,  and  initial  chills  are  very  rare.  In  tlie 
prognosis  of  septicaemia  the  conditions  of  the  pulse  and  tongue  are 
more  important  than  the  temperature,  A  small  frequent  pulse 
and  dry  tongue  are  bad  signs ;  while  a  normal  temperature  has  no 
prognostic  value,  very  high  or  very  low  temperature  makes  the 
prognosis  worse. 

This  is  the  usual  course  of  acute  piu-e  septicaemia  from  recent  in- 
juries ;  but  the  patient  may  die  in  the  first  stages,  with  rising  tempera- 
ture. Cases  also  occur  where  the  onset  of  the  fever  is  scarcely  marked 
by  an  elevation  of  temperature,  and  lastly  some  cases  run  their  course 
without  fever  or  with  abnormally  low  temperature ;  the  latter  occurs 
especially  in  old  persons  with  spontaneous  gangrene ;  but  the  other 
symptoms  above  mentioned  usually  exist.  From  this  and  particularly 
from  the  above  curve,  we  see  that  falling  of  the  temperature  of  itself 
is  by  no  means  a  sign  of  improvement,  but  that  the  other  constitutional 
symptoms  (strength,  mental  state,  tongue,  pulse,  etc.)  must  also  be 
taken  into  consideration. 

I  hope  that,  from  what  has  been  said,  you  have  formed  a  true  idea 
of  septicaemia.  Where  the  symptoms  of  the  disease  are  marked,  the 
prognosis  is  very  bad ;  we  shall  speak  of  the  treatment  at  the  end  of 
this  section. 

We  now  come  to  the  post-mortem  appearances.  Occasionally  it 
is  difficult  for  us  to  recognize  on  the  cadaver  the  oedematous  infiltration 
and  brownish  discoloration  of  the  skin  that  we  observed  about  the 
wound  during  life.  In  other  cases  that  had  a  long  course  (six  to  eight 
days)  we  find  the  subcutaneous  tissue  infiltrated  with  bloody,  serous 
fluid ;  where  the  course  is  stiU  longer  (two  weeks  or  more)  the  disease 
shows  itself  mostly  by  expensive  suppuration  of  the  cellular  tissue, 
vith  more  or  less  extensive  gangrene  of  the  skin.  Frequently  the  in- 
ternal organs  present  no  morbid  appearances.  If  there  was  continued 
profuse  diarrhoea  during  life,  you  find  swelling  of  the  solitary  and 
conglobate  intestinal  follicles.  The  spleen  is  often  enlarged  aTid 
softened,  rarely  it  is  of  a  normal  size  and  firmness ;  the  liver  is  usually 
full  of  blood,  relaxed,  and  very  friable,  but  without  further  change. 
In  the  heart  the  blood  is  lumpy,  half-clotted,  tarry,  and  rarely  firmly 
coagulated,  buffy ;  in  most  cases  the  lungs  are  normal.  Sometimes 
we  find  diffuse  single  or  double  pleurisy  of  moderate  extent,  and  alsc 
traces  of  pericarditis.  Under  p}  eemia  we  shall  speak  more  fully  of 
these  diffuse  metastatic  inflammations  which  are  not  due  to  emboli 


408  PYiEMIA. 

bere  it  is  not  very  necessary  to  do  so  any  more  than  it  is  to  treat  of 
embolic  infarctions  and  putrid  abscesses,  which  are  exceptionally 
found  in  septicaemia  when  the  patients  resist  the  disease  a  long  time, 
and  venous  thrombi  have  occurred  about  the  wound  or  gangrenous  spot. 
As  nothing  special  has  been  foimd  on  chemical  analysis  of  the  blood 
from  the  bodies  of  such  cases,  it  must  be  acknowledged  that  what  we 
find  post  mortem  adds  little  that  is  characteristic  to  the  picture  of  the 
disease,  which  is  essentially  etiologico-symptomatological ;  if  we  have 
not  seen  the  patient  during  life,  we  shall  often  examine  the  dead  body 
in  vain  for  some  palpable  cause  of  death. 

3.  Suppuratwe  Fever^  Pycem,ia. — Pyaemia  (the  name  was  formed  by 
Piorry  from  txvov,  pus,  and  alfia,  blood)  is  a  disease  which  we  suppose 
to  be  due  to  the  absorption  of  pus  or  its  constituents  into  the  blood; 
it  holds  the  same  relation  to  simple  inflammatory  and  suppurative 
fever  that  septicaemia  does  to  simple  primary  traumatic  fever;  it  is 
symptomatologically  characterized  by  intermittent  attacks  of  fever,  and 
in  its  pathological  anatomy  by  the  frequency  of  metastatic  abscesses 
and  metastatic  diflFuse  inflammations.  Other  names  for  this  disease  are : 
metastatic  suppurative  dyscrasia,  pus  disease,  purulent  diathesis. 

To  give  you  at  once  an  approximate  picture  of  this  disease,  I  will 
describe  for  you  a  case  of  pyaemia. 

A  wounded  patient  enters  the  hospital  with  a  compound  fracture 
of  the  leg  just  above  the  ankle.  The  injury  has  resulted  from  the 
fall  of  a  heavy  body.  You  examine  the  wound,  find  an  oblique  frac- 
ture of  the  tibia,  but  consider  the  injury  of  such  a  nature  that  it  may 
heal.  So  you  apply  a  dressing  ;  at  first  the  patient  feels  very  well ; 
he  has  but  little  fever  till  about  the  third  or  fourth  day,  then  the 
wound  becomes  more  inflamed,  secretes  relatively  little  pus,  the  sur- 
rounding skin  becomes  cedematous  and  red,  the  patient  grows  very 
feverish,  especially  toward  evening,  the  swelling  about  the  wound  in- 
creases and  slowly  spreads,  the  whole  leg  grows  swollen  and  red,  the 
ankle-joint  very  painful ;  on  pressure  over  the  leg,  a  thin,  bad-smell- 
ing pus  flows  slowly  from  the  wound ;  the  swelling  remains  limited  to 
the  leg ;  there  is  no  trouble  of  the  mind,  no  sign  of  intense,  acute 
septicaemia ;  the  patient  is  exceedingly  sensitive  to  every  dressing,  he 
is  restless  and  discouraged ;  there  is  febris  continua  remittens,  with 
high  evening  temperature,  and  frequent,  full,  tense  pulse ;  the  appe- 
tite is  lost,  and  the  tongue  heavily  coated.  This  would  be  about  the 
twelfth  day  after  the  injury.  Quantities  of  pus  flow  from  different 
parts  of  the  wound ;  somewhat  above  it  fluctuation  is  distinct ;  this 
collection  of  pus  may  be  evacuated  through  the  wound  by  careful  press- 
ure, but  the  escape  is  greatly  impeded,  and  an  incision  must  be  made 
at  the  above  point.     This  being  done,  a  moderate  quantity  of  pus  is 


TRAUMATIC  AND   INFLAMMATORY   DISEASES,   ETC.  409 

evacuated ;  a  few  hours  later  the  patient  has  a  severe  chill,  then  dry 
burning  heat,  and,  lastly,  profuse  sweating.  The  appearance  of  the 
wound  improves  somewhat ;  but  this  does  not  last  long  ;  we  soon  no- 
tice a  new  abscess  near  the  wound,  but  rather  behind  it  in  the  calf ; 
there  is  another  chill ;  more  counter-openings  are  required  at  different 
spots  to  give  exit  to  the  pus,  which  forms  in  quantities.  The  left  leg 
is  the  injured  one ;  some  morning  the  patient  complains  of  great  pain 
in  the  right  knee-joint,  which  is  somewhat  swollen,  and  is  painful  on 
every  motion.  The  nights  are  sleepless,  the  patient  eats  very  little, 
d links  a  great  deal,  and  becomes  much  debilitated;  he  emaciates, 
especially  in  the  face,  the  color  of  the  skin  changes  to  yellowish,  the 
chills  recur;  the  patient  then  begins  to  complain  of  pressure  on  the 
chest ;  he  coughs  some,  but  raises  little  sputum ;  on  examining  the 
chest,  you  find  a  moderate  pleuritic  exudation  on  one  or  both  sides, 
from  which,  however,  the  patient  does  not  suffer  much,  but  he  com- 
plains more  of  the  right  knee,  which  is  now  much  swollen,  and  con- 
tains a  great  deal  of  fluid ;  as  the  patient  sweats  a  great  deal,  the 
urine  becomes  very  concentrated,  and  is  occasionally  albuminous. 
Finally,  there  is  decubitus,  but  the  patient  does  not  complain  much 
of  this ;  he  lies  quietly,  half  insensible,  muttering  to  himself.  This 
would  be  about  the  twentieth  day  after  the  injury  ;  the  wound  is  dry, 
the  patient  looks  miserable ;  the  face,  and  especially  the  neck,  is  ema- 
ciated, the  skin  is  very  jaundiced,  the  eyes  dull,  the  trembling  tongue 
is  perfectly  dry,  the  skin  cool,  the  temperature  low,  and  only  elevated 
at  evening,  the  pulse  small  and  frequent,  the  respirations  slow,  the 
breath  of  a  peculiar  cadaveric  odor ;  the  patient  becomes  entirely  un- 
conscious, and  may,  perhaps,  remain  so  for  twenty-four  hours  before 
death.  On  autopsy,  you  find  nothing  pathological  in  the  skull ; 
heart  and  pericardium  normal ;  in  the  right  auricle  and  ventricle  a 
firmly-coagulated,  white,  fibrinous  clot ;  both  pleural  cavities  are  filled 
with  a  cloudy,  serous  fluid ;  the  surfaces  of  the  lungs  are  covered  with 
a  net-like  layer  of  jaundiced  fibrine ;  on  tearing  this  off,  under  it,  in  the 
substance  of  the  lung,  but  particularly  on  its  siu-face,  you  find  quite 
firm  nodules,  as  large  as  a  bean  or  chestnut.  These  are  found  chiefly 
in  the  lower  lobes  ;  sections  through  them  show  that  they  are  mostly 
abscesses.  The  parenchyma  of  the  lungs,  somewhat  condensed,  forms 
the  capsule  of  a  cavity,  which  is  filled  with  pus  and  disintegrated 
lung-tissue ;  others  of  these  nodules  are  bloody  red,  and,  on  section, 
the  cut  surface  is  somewhat  granular,  and  in  their  midst  there  are  oc- 
casional spots  of  pus  of  various  size,  and  it  is  evident  that  they 
change  to  abscesses.  They  are  the  red  infarctions,  terminating  in 
abscesses,  with  which  you  are  already  acquainted.  Some  of  these 
abscesses  lie  so  near  the  surface  that  they  implicate  the  pleura,  and 


410  PYEMIA. 

the  pleuritis  is  secondary.  Tlie  liver  is  quite  vascular  and  friable,  but 
is  otherwise  apparently  normal.  The  spleen  is  somewhat  enlarged, 
and,  on  section,  shows  a  few  firm,  wedge-shaped  nodules,  with  their 
points  inward,  and  their  broad  outer  ends  along  the  surface ;  they  re- 
semble the  red  infarctions  of  the  lungs,  and  within  they  also  have 
partly  broken  down  into  pus.  The  intestines,  urinary  and  genital 
organs,  show  nothing  abnormal.  An  incision  into  tlie  right  knee, 
which  was  painful  during  life,  evacuates  a  quantity  of  flocculent  pus ; 
the  synovial  membrane  is  swollen,  and  in  part  heemorrhagic,  injected ; 
the  lustre  of  the  articular  cartilage  is  dulled.  Examination  of  the 
wound  shows  little  more  than  we  found  on  the  living  patient ;  that  is, 
extensive  suppuration  of  the  deep  and  subcutaneous  cellular  tissue,  as 
well  as  pus  in  the  ankle-joint ;  the  walls  of  all  these  collections  of  pus 
consist  mostly  of  broken-down  tissue,  true  granulation  has  only  oc- 
curred at  a  few  points.  Tlie  fracture  is,  however,  more  complicated 
than  had  been  supposed,  for  a  longi^-udinal  fissure  reaches  to  the 
ankle-joint,  and  on  the  posterior  aspect  of  tlie  tibia,  which  we  could 
not  examine  during  life,  there  are  several  detached  fragments  of  bone. 
In  the  veins  of  the  leg  there  are  old  plugs  of  fibrine  here  and  there, 
also  yellow  puriform  detritus,  and  in  some  places  pure  pus. 

Let  us  make  some  reflections  on  this  case,  and  suppose  that  you 
have  seen  a  series  of  such  cases,  so  that  you  are  convinced  that  it  is 
not  an  accidental  association  of  various  diseases,  but  a  regular  com- 
bination. You  have  an  extensive,  steadily-increasing  suppuration  in 
an  extremity,  with  intense  continued  fever,  which  has  exacerbations. 
To  this  are  added  suppuration  in  some  distant  joint,  and  circumscribed 
inflammations,  ending  in  formation  of  abscesses  in  the  lungs  and  other 
organs.  These  multiple  points  of  inflammation  keep  up  the  fever, 
and  they  disturb  the  functions  of  the  affected  organs,  and  the  patient 
dies  of  exhaustion.  The  peculiar  and  essential  feature,  as  you  will 
readily  see,  is  the  appearance  of  various  points  of  inflammation,  after 
the  primary  suppuration  has  attained  a  certain  grade.  You  know  the 
explanation  of  the  occurrence  of  metastatic  abscesses :  they  are  al- 
ways caused  by  venous  thrombosis  and  embolism ;  it  is  unnecessary 
to  recur  to  this.  It  is  more  difiicult  to  explain  the  diffuse  metastatic 
inflammations  which  occur  both  in  septicaemia  and  pj'OBmia ;  they  by  no 
mee.ns  always  depend  on  abscesses  of  the  lungs,  as  does  pleurisy  m 
the  cases  above  mentioned ;  there  are  metastatic  diffuse  abscesses  of 
the  eye,  cerebral  membranes,  subcutaneous  tissue,  joints,  periosteum, 
'.iver,  spleen,  kidnej's,  pleura,  pericardium,  etc.,  which  are  independent 
of  abscesses  or  emboli.  The  occurrence  of  these  metastases  cannot 
always  be  exactly  explained.  If  the  metastatic  disease  be  nearly 
united  to  the  original  abscess,  it  might  be  attributed  to  conduction 


TRAUMATIC  AND   INFLAMMxVTORY   DISEASES,   ETC.  411 

of  the  inflammation  from  the  latter,  possibly  through  the  lymphatic 
vessels ;  as  in  cases  where,  after  amputation  of  the  breast  or  exar- 
ticulation  of  the  humerus,  there  is  pleurisy  of  the  same  side,  or  a 
fracture  of  the  lower  third  of  the  leg  is  accompanied  by  suppuration 
of  the  knee-joint.  In  other  cases  it  is  possible  that  a  part  already 
diseased,  or  predisposed  to  inflammation,  becomes  acutely  afi"ected,  as 
a  result  of  the  general  febrile  disturbance ;  for  instance,  sometimes 
fracture  callus,  say  of  the  radius,  that  is  already  tolerably  firm,  sup- 
purates in  the  third  or  fourth  week,  if  the  patient  becomes  pyemic 
from  a  complicated  fracture  of  the  leg,  or  from  a  bed-sore.  But  there  are 
many  cases  where,  as  above  stated,  such  explanations  prove  insufiicient. 
Then  we  trj'  to  satisfy  ourselves  that  there  was  a  predisposition  to  in- 
flammations, especially  to  suppuration  in  certain  organs,  which  is 
necessarily  accompanied  by  pus-poisoning ;  that  the  pus-poison  circu- 
lating in  the  blood  has  a  specific  phlogogenous  action  on  certain  organs. 
I  can  give  you  no  farther  explanation  on  this  point,  but  would  like  to 
render  this  hypothesis  a  little  more  plausible  to  you,  by  comparing  it 
with  analogous  observations  on  the  specific  phlogogenous  action  of 
certain  drugs,  of  which  we  have  already  spoken  when  treating  of  the 
etiology  of  inflammation,  and  its  toxic-miasmatic  causes,  and  their 
mode  of  action  (Lee.  XXI).  Diffuse  metastatic  inflammations  of  in- 
ternal organs  are  rare,  unless  among  them  we  include  the  diffuse  en- 
largement of  the  spleen,  which  is  frequent,  if  not  constant,  in  pyaemia. 
The  diagnosis  of  metastatic  abscesses  and  inflammations  is  easy,  where 
they  lie  at  the  surface  of  the  body  and  extremities ;  metastatic  me- 
ningitis or  choroiditis  is  relatively  easy  to  recognize.  The  diagnosis 
of  metastases  to  the  lung  may  prove  difficult ;  the  foci  are  often  so 
small  and  so  scattered  in  the  lung  that  they  cannot  be  detected  by 
percussion ;  the  accidental  pleuritic  effusion  often  aids  in  the  diagnosis 
of  metastatic  pulmonary  abscesses  ;  if  there  are  bloody  sputa  and 
severe  bronchial  catarrh,  the  diagnosis  may  be  considered  certain ;  the 
subjective  symptoms  are  often  very  slight ;  the  dyspnoea  is  only  severe 
when  there  is  extensive  pleuritic  effusion.  In  pyjemia  there  is  often 
more  or  less  jaundice.  It  is  not  yet  fully  determined  whether,  in  these 
cs  ses,  the  coloring  matter  of  the  bile  is  formed  from  the  red  coloring 
nratter  of  the  blood  without  the  intervention  of  the  liver,  or  if  icterus 
ever  can  occur  Avithout  the  liver  having  something  to  do  with  it,  al- 
though most  observers  regard  it  as  always  being  hepatogenous.  At 
all  events,  icterus  in  pyaemia  does  not  admit  a  diagnosis  of  abscess  of 
tlie  liver ;  this  may  be  suspected  if  there  be  great  pain  in  the  hepatic 
njgion,  but,  instead  of  the  expected  hepatic  abscess,  I  have,  in  such 
cases,  occasionally  found  acute  diffuse  softening  of  the  liver,  which 
was  accompanied  by  almost  bronze-like  icterus.     Enlargement  of  tha 


412 


PYEMIA. 


spleen  may  sometimes  be  diagnosed  by  percussion.  Occasionally, 
albumen,  with  epithelial  and  gelatinous  casts  and  blood  in  the  urine, 
especially  if  there  be  considerable  coincident  decrease  in  the  amount 
of  urine  excreted,  justifies  a  diagnosis  of  acute  metastatic  nephritis"; 
but  during  life  it  cannot  be  certainly  determined  whether  the 
kidney  has  numerous  metastatic  abscesses  or  is  diffusely  inflamed, 
as  may  also  occur  metastatically.  Pulmonary  and  splenic  abscesses, 
as  well  as  articular  inflammations,  are  the  most  frequent,  while  those 
of  the  liver,  kidneys,  and  other  parts  above  mentioned,  are  far  more 
rare. 

There  is  one  symptom  of  pyasmia  that  we  must  study  more  care- 
fully, viz.,  chills.  They  occur  irregularly,  rarely  at  night,  although 
they  may  come  at  any  time  of  day,  and  their  duration  and  intensity 
vary  exceedingly ;  sometimes  the  patient  only  complains  of  slight 
cnilliness  and  temporary  shivering,  sometimes  he  trembles  and  chat- 
ters his  teeth  as  hard  as  in  "  chills  and  fever."  At  first  the  chills  come 
rarely,  then  more  frequently,  two  or  three  times  daily ;  toAvard  the 
end  they  again  abate.  The  attacks  themselves  resemble  those  of 
intermittent  fever  in  regard  to  chill,  dry  heat,  and  sweating ;  but  after 
the  attack  there  is  no  complete  cessation  of  the  fever,  it  almost  al- 
ways continues  to  some  extent.  Now,  what  is  the  true  nature  of  this 
chill  ?  AMien  we  have  opjiortunity  to  make  observations  on  ourselves 
v\'e  find  that  there  is  a  spasmodic  contraction  in  the  skin ;  we  must 
spasmodically  knock  the  teeth  together,  even  against  our  will ;  if  this 
ceases  for  a  moment,  we  do  not  feel  cold,  but  rather  hot,  and  the 
feeling  of  chilliness  is  more  in  the  imagination,  for  otherwise  we  only 
have  similar  sensations  and  spasmodic  trembling  as  an  efl'ect  of  great 
cold.  During  the  chill  the  limbs  and  skin  feel  cold,  as  the  blood  has 
Ijeen  driven  from  the  capillaries  by  the  spasm  of  the  cutaneous  mus- 
cles. But  if  you  measure  the  bodily  temperature  with  the  thermom- 
eter from  the  commencement  of  the  chill,  you  find  that  the  tempera- 
ture rises  constantly  and  rapidly,  occasionally  from  3°  to  5°  Fahr.,  in 
a  quarter  or  half  an  hour.  At  the  end  of  the  chill,  and  during  the 
period  of  dry  heat,  the  bodily  temperature  usually  attains  its  highest 
point ;  it  may  reach  108°  Fahr.,  but  rarely  goes  over  104.5°  Fahr. ; 
from  this  point  it  gradually  declines.  The  rapid  increase  of  temper- 
ature is  alwa^-s  in  proportion  to  the  phenomena  of  the  chill ;  a  cer- 
tain irritability  of  the  nervous  system  also  appears  necessary  for  its 
occurrence,  for  in  torpid  or  narcotized  persons  chills  are  much  more 
rare  than  in  very  irritable  subjects  (see  page  184). 

The  most  varied  acute  diseases  begin  with  chills  and  fever,  espe- 
cially the  acute  exanthemata,  pneumonia,  lymphangitis,  etc. ;  more 
rarely  the  acute  miasmatic  infectious  diseases,  such  as  typhus,  plague. 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,   ETC.  413 

anil  cholera.  Usually,  however,  these  chills  are  not  repeated,  but 
only  the  onset  of  the  disease  is  accompanied  by  this  symptom ;  it 
seems  as  if  the  first  entrance  of  certain  pyrogenous  substances  into 
the  blood  of  persons  otherwise  healthy  was  especially  apt  to  induce 
chills,  or  as  if  certain  infectious  materials  entering  the  blood  excited 
particularly  intense  fever  with  chills.  Hence,  although  we  cannot 
consider  chills  a  characteristic  of  pyaemia,  still  their  frequent  recur- 
rence, as  well  as  the  generally  intermittent  type  of  the  fever,  is  pecu- 
liar to  this  disease.  Intermittent  fever  is  the  only  disease  in  which 
we  see  any  thing  similar  ;  there  we  have  intermittent  attacks  of  fever 
with  regular  intervals  ;  we  do  not  know  on  what  this  interval  depends, 
but  I  should  consider  the  immediate  cause  of  the  attacks  of  fever  to 
be  paroxysmal  pouring  out  of  morbid  products  from  the  spleen  ;  in 
melanremia  and  pigment  metastases  we  have  anatomical  evidence 
that  in  intermittent  fever  substances  pass  from  the  spleen  into  the 
blood ;  it  is  known  that  collections  of  normal  secretion  occur  in  the 
pancreas  and  spleen,  and  are  poured  out  during  digestion  ;  hence,  it 
does  not  seem  to  me  too  bold  to  assume  that,  with  these  physiological 
evacuations  of  certain  substances  from  the  spleen,  pathological  prod- 
ucts may  also  enter  the  blood.  Thus,  in  pyaemia,  from  time  to  time 
pus  or  its  constituents  might  be  poured  into  the  blood,  and  under 
otherwise  favorable  circumstances  fever  and  chills  might  be  induced. 
Extensive  progressive  inflammation  about  the  wound  must  be  re- 
garded as  the  chief  source  of  such  repeated  purulent  infection  ; 
destruction  of  the  granulating  surface  by  frequent  injury,  rapid  de- 
struction of  the  granulations  by  chemical  agents,  any  new  progressive 
inflammations  occurring  about  the  wound,  may  open  an  entrance  for 
the  pus  into  the  lymphatic  vessels  which  have  been  closed  ;  new  in- 
flammation may  cause  suppuration  of  the  coagula  in  the  lymphatic 
vessels,  and  the  pus  fro^n  these  may  enter  the  blood  ;  it  might  also 
be  imagined,  although  difficult  to  prove,  that  in  venous  thrombosis  the 
central  coagula  enclosing  the  pus  in  the  veins  are  torn  loose,  and  the 
pus  is  swept  into  the  blood  through  a  passable  collateral  vein,  which 
opens  farther  on ;  this  might  be  caused  by  muscular  contractions. 
Lastly,  metastatic  inflammations,  whether  due  to  emboli  or  not,  also 
induce  new  attacks  of  fever ;  but  that  this  is  not  the  only  cause  is 
proved  by  occasional  autopsies  on  cases  that  have  died  from  intermit- 
tent purulent  fever,  after  ten  or  twelve  chills,  where  no  metastat'o 
inflammations  have  been  found;  the  cause  of  the  repeated  chills  may 
then  lie  in  the  mode  of  extension  of  the  local  process,  or  be  hidden 
in  the  bones  or  elsewhere.  Statistics  greatly  favor  the  idea  that 
the  chills  depend  on  new  inflammations,  for  they  show  that  the  chills 
(or  at  least  the  intermittent  fever  attacks,  which  may  occur  withoul 


414  PYEMIA. 

chills)  occur  far  more  frequently  in  persons  in  whom  subsequeni 
autopsy  shows  inflammation  of  internal  organs  than  in  those  where 
this  is  not  the  case.  It  must  be  mentioned,  as  a  matter  of  observa- 
tion, that  chills  occur  almost  exclusively  in  the  commencement  of 
acute  inflammations,  and  are  intermittent  only  in  intermittent  fever 
and  reabsorption  of  pus,  while  they  do  not  occur  in  acute  septicEemia. 
Probably  the  chemical  qualities  of  the  infecting  matter  here  play  an 
important  but  unknown  role.  Unfortunately,  experiment  here  leaves 
us  entirely  in  the  dark ;  I  have  never  succeeded  in  exciting  chills  or 
intermittent  attacks  in  rabbits,  dogs,  or  horses,  by  injections  of  putrid 
substances  or  good  pus  ;  pus  and  putrid  matter  have  the  same  ac- 
tion on  animals,  as  regards  fever  ;  we  can  only  artificially  excite  the 
intermittent  course  of  the  fever  in  animals  by  repeating  the  injec- 
tions. 

From  what  you  have  just  heard,  you  will  understand  that  the  usual 
method  of  measuring  temperature  morning  and  evening  can  give 
no  picture  of  the  course  of  the  fever  in  pyaemia ;  for  in  this  way  the 
measurement  may  fall  at  one  time  in  the  acme,  again  in  the  deferves- 
cence of  an  attack  of  fever,  or  at  another  time  in  the  remission  (com- 
plete intermission  of  the  fever  rarely  happens  in  pyeemia)  ;  thus  we 
would  of  course  have  very  irregular  fever-curves.  To  obtain  an  ac- 
curate picture  of  pyaemic  fever,  it  would  be  necessary  to  leave  the 
thermometer  constantly  in  position,  and  to  note  the  temperature 
every  hour  or  so ;  as  this  would  greatly  annoy  the  patient,  and  we 
have  enough  other  signs  to  decide  the  prognosis  and  treatment,  I 
have  been  unable  to  make  up  my  mind  to  do  this.  Tlie  investiga- 
tions as  to  whether  pyemic  pus  contains  peculiar  substances,  or  its 
qualitative  composition  diff'ers  from  that  of  the  pus  in  persons  who 
recover  without  any  complications,  have  thus  far  proved  without  re- 
sult. The  pus  of  pyosmic  patients  does  not.  always  smell  bad,  nor 
always  contain  cocci ;  still  cases  where  putrid  pus  containing  cocci 
enters  the  circulation  are  the  more  frequent.  We  do  not  know 
whether  the  pus  coccus  grows  after  entering  the  blood.  I  have  not 
found  cocci  and  bacteria  in  the  blood  of  pyaemic  patients. 

The  mode  of  onset  of  pyaemia  varies  in  some  respects.  Most  fre- 
quently this  disease,  which  we  regard  as  a  peculiar,  malignant  form 
of  suppurative  fever,  begins  when  suppmation  begins,  or  later,  when 
new  inflammations  occur  about  the  Avound,  whether  they  be  imme- 
diately connected  with  the  traumatic  inflammation,  or  occur  acciden- 
tally after  the  point  of  traumatic  inflammation  has  been  bounded. 
Tlien  the  pygemic  fever  develops  from  the  traumatic  fever,  or  from  the 
secondary  fever,  and  in  such  cases  these  are  considered  by  some  ob- 
servers as  prodromal  stages  of  pyaemia.     The  moment  when  the  ])a 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC.  415 

tient  becomes  pyemic  cannot  be  decided  any  more  accurately  than 
can  the  passage  of  primary  traumatic  fever  into  septicaemia.  I  retain 
the  designation  "  pyaemia  "  for  the  disease  just  described.  I  have  told 
you  that  the  reabsorption  of  pus  is  the  cause  ;  intermittent  course  of  the 
fever,  with  rapidly-increasing  marasmus,  the  chief  symptom  ;  and  the 
metastatic  inflammations  very  essential  anatomical  conditions  ;  but  it 
is  sometimes  very  difficult  to  decide  whether  a  given  case  shall  be 
termed  severe  traumatic  fever,  septicaemia ;  or  severe  suppurative 
fever,  pyaemia.  The  chills  may  not  occur ;  then  it  is  difficult  to  de- 
termine the  intermittent  course  of  the  fever ;  the  metastases  may  not 
be  diagnosticated  during  life.  If  you  have  a  case  of  osteomyelitis 
with  frequent  chills,  if  the  patient  dies  and  you  find  no  metastases,  is 
that  pyaemia  ?  Or  an  old  marasmic  man  has  a  compound  fracture ;  he 
dies  with  symptoms  of  complete  exhaustion  in  the  fourth  week,  with- 
out having  had  very  high  fever  or  chills ;  you  find  no  metastases  ;  is 
that  pygemia  ?  For  the  beginner  who  would  like  to  have  every  thing 
well  systematized,  these  questions,  and  their  doubtful  answers,  are 
very  embarrassing.  You  will  find  surgeons  who  call  the  above  cases 
pyaemia,  others  who  term  them  simply  intense  suppurative  fever  or 
febrile  marasmus.  If  you  adhere  to  the  above  description,  and  have 
correctly  comprehended  the  relation  of  infection  to  venous  throm- 
bosis and  embolism,  it  is  to  be  hoped  you  will  not  be  perplexed  about 
the  names.  Indeed,  it  is  scarcely  possible  to  make  a  name  for  every 
link  between  septicaemia,  purulent  infection,  diffuse  metastatic  inflam- 
mations, thrombosis,  embolism,  etc.  For  instance,  septicaemia  occurs 
without  a  trace  of  metastases,  with  diffuse  metastases,  with  throm- 
bosis and  embolism  ;  purulent  infection  without  a  trace  of  metastases, 
with  diffuse  metastases  and  thrombi,  with  thrombi  alone,  with  thrombi 
and  emboli ;  there  are  thrombi  with  local  sequences  without  emboli, 
with  emboli,  with  haemorrhagic  effusions,  with  apoplexies,  etc.  Be- 
sides the  words  already  given,  some  others  have  been  introduced  to 
designate  combinations  of  the  various  processes.  For  pure  purulent 
infection  (infection  with  thin,  bad  pus — ichor)  Virchow  has  proposed 
the  name  icJiorrhcemia.  0.  Weber  uses  the  name  enibolhcBmia  for  the 
condition  in  which  emboli  are  found  in  the  blood.  The  classification 
given  by  Meuter^  in  his  excellent  work  on  this  subject,  appears  to  me 
very  practical.  In  pure  cases  of  purulent  infection  without  metastases 
he  calls  the  disease  "pyoh^emia  simplex;"  in  cases  with  metastases, 
"  pyohaemia  multiplex." 

The  course  of  purulent  infection  is  usually  acute  (8-10  days), 
often  subacute  (2-4  weeks),  rarely  chronic  (1-3-5  months).  The  ra- 
pidity of  the  acute  cases  is  due  partly  to  the  intensity  and  frequent 
repetition  of  the  infection,  partly  to  the  extent  of  the  metastase? 


416  PYEMIA. 

The  chronic  cases  usually  occur  in  very  strong  or  tough  patients,  and 
the  infection  is  only  moderately  intense,  and  not  often  repeated  ;  the 
metastases  are  in  external  parts,  as  abscesses  in  the  cellular  tissue, 
and  suppurations  of  the  joints,  which  keep  the  patient  sick  after  the 
other  results  of  purulent  infection  have  disappeared.  The  prognosis 
essentially  depends  on  the  course.  The  more  frequently  the  chills  are 
repeated,  the  more  rapidly  strength  is  lost ;  the  earlier  the  symptoms 
of  internal  metastases  present  themselves,  the  sooner  the  patient  will 
die.  The  longer  the  intermissions  between  the  exacerbations  of  fever, 
the  better  the  strength  is  preserved ;  the  longer  the  tongue  remains 
moist,  the  more  hope  we  have  of  the  patient's  recovery  ;  he  is  not  out 
of  immediate  danger  till  the  wound  again  looks  well,  till  he  has  been 
entirely  free  from  fever  for  several  days,  and  has  otherwise  the  ap- 
pearance of  a  convalescent.  It  is  exceedingly  rare  for  a  patient  who 
presents  all  the  above  symptoms  of  decided  pyaemia  to  recover. 

[It  is  only  in  the  last  ten  years  that  accurate  diagnosis  between 
septicseraia  and  pysemia  has  been  possible,  and  this  is  based  on  the 
etiology,  clinical  course,  and  anatomy  ;  now  this  differentiation  is 
assailed.  It  is  asserted  that  the  poison  is  the  same  in  traumatic 
fever,  septicaemia,  and  pyaemia  ;  that  it  is  always  the  product  of 
coccus  proliferation  ;  but  I  cannot  entirely  agree  with  this  view. 
Quite  recently  we  have  had  an  excellent  work  on  this  point  by 
Jlohert  Koch :  he  induced  traumatic  infectious  diseases  in  animals, 
and  then  examined  their  tissues  microscopically.  lie  thinks  the 
different  infectious  processes,  septictemia,  progressive  gangrene, 
pyaemia,  and  erysipelas,  are  due  to  different  forms  of  vegetation 
which  may  be  recognized  as  distinct  forms  of  cocci  by  the  micro- 
scope. Koch  thinks  that,  besides  the  fungi  acting  deleteriously  and 
multiplying  in  the  organism,  there  are  others  which  arc  either  not 
injurious  for  certain  animals,  or  else  do  not  develop  in  animals. 

Although  Koch  originally  inoculated  with  putrid  fluids,  he  comes 
to  the  conclusion  that  it  is  possible  to  transfer  a  certain  species  or 
various  forms  together  to  the  same  animal,  and  thus  induce  one  of 
the  above  diseases  or  a  combination  of  several  of  them.  Satisfac- 
tory as  it  might  be  to  do  so,  it  is  not  yet  possible  to  refer  the  trau- 
matic infectious  diseases  in  man  to  carefully-studied,  characterized 
contagions  ;  although  there  is  great  probability  of  the  existence  of 
different  infecting  materials,  and  of  the  parasitic  nature  of  at  least 
part  of  the  accidental  diseases  of  wounds.  But  the  clinical  picture 
of  the  above  states  is  in  most  cases  varied  enough  to  distinguish 
them  ;  and  should  it  once  be  decided  that  the  difference  was  only  due 
to  more  or  less  intense  action  of  the  same  chemical  process,  it  would 
be  very  satisfactory  scientifically,  though  it  would  not  diminish 


SEPTICEMIA.  417 

the  clinical  and  prognostic  value  of  the  descriptions  of  the  diseases. 
From  individual  observation  I  can  confirm  I£ueter''s  proposed  name 
of  "  septo-pysemia  "  f or  a  disease  where  the  clinical  symptoms  of 
septica?mia  and  pyemia  pass  into  each  other.  The  term  "  subacute 
pyaemia,"  used  by  Strortieyer  and  others,  corresponds  to  septicaemia. 
The  French  "gangrene  traumatique  f oudroyante  "  is  accompanied 
by  development  of  gas  deep  in  the  muscles,  green  discoloration,  and 
rapid  decomposition  of  the  tissues  during  life  ;  it  is  very  rare  ;  I 
have  only  seen  two  cases  after  amputation  of  the  thigh  for  severe 
injuries.  In  some  such  cases  the  gangrene  is  caused  by  the  injury, 
as  when  the  tissue  has  been  extensively  crushed  and  killed,  without 
the  fact  being  recognized  at  the  time  of  the  injury.  But  in  other 
cases  contusion  might  be  excluded  and  still  the  gangrene,  with  de- 
velopment of  gas,  proceeded  rapidly.  Probably,  under  especially 
favorable  conditions,  there  may  be  developed  substances  of  such 
activity  as  snake-poison,  etc.,  whose  contact  at  once  destroys  this 
life  of  the  cells. 

We  can  rarely  recognize  purulent  breaking  up  of  the  thrombosis 
in  a  vein  ;  if  a  few  days  after  an  amputation  the  patient  has  a  chill, 
we  may  suspect  a  purulent  infiltration  of  ^  venous  thrombus.  In 
some  such  cases,  exposure  of  the  chief  venous  trunk,  pinching  it 
together  and  dividing  its  wall,  turning  out  the  coagulum  and  cutting 
out  the  diseased  part  of  the  vein,  applying  a  ligature  in  the  healthy 
tissue,  has  arrested  the  general  infection  and  saved  the  patient. 
Hunter  suggested  compressing  the  veins  in  suppurative  thrombo- 
phlebitis, but  unfortunately  this  is  only  practicable  in  a  few  cases, 
as  after  amputation  ;  while  it  is  scarcely  possible,  in  pyemia  after 
complicated  fractures,  to  recognize  early  the  location  of  the  decom- 
posing thrombus,  unless  it  be  in  some  large  subcutaneous  vein.  In 
acute  sepsis  the  local  treatment  is  most  important.  Bad  as  are  the 
results  of  amputation  in  such  cases,  we  still  have  to  operate  and 
risk  seeing  the  stump  become  gangrenous.  In  gangrene  foudroyante, 
or  gangr.'ena  septica  acutissima,  energetic  antiseptic  treatment,  mul- 
tiple incisions,  removal  of  gangrenous  tissue,  applications  of  a  five- 
per-cent.  solution  of  chloride  of  zinc,  and  permanent  irrigation, 
may  save  the  patient.  At  all  events,  do  not  be  deterred  by  the  ap- 
parent hopelessness  of  the  case  from  trying  something.] 

The  severest  cases  of  septicaemia  are  those  where  toward  the 
middle  or  end  of  the  second  day  great  cyanosis  and  collapse  come 
on  rapidly  ;  then  death  usually  occurs  in  a  few  hours.  Such  pa- 
tients look  like  those  in  the  algid  stage  of  cholera,  only  in  septi- 
caemia vomiting  and  persistent  diarrhoea  are  rare  ;  after  getting 
along  well  perhaps  for  twenty -four  hours  after  the  operation,  the 
28 


418  TRAUMATIC  AXD   INFLAMMATORY  DISEASES,  ETC. 

patients  seem  as  if  poisoned.  In  these  cases  (which  may  be  accom- 
panied by  dij^htheria)  the  secretion  from  the  wound  does  not  always 
smell  disagreeably.  It  cannot  be  shown  that  the  intoxicating  mat- 
ter in  these  cases  is  different  from  usual,  or  that  the  inflammatory 
alteration  of  tissues  causes  a  remarkable  amount  of  poisonous  prod- 
uct. According  to  the  above,  the  variety  of  symptoms  in  septi- 
caemia is  considerable  ;  but  this  proves  nothing  against  the  claim 
that  the  septic  poison  is  always  the  same,  for  there  is  the  same  dif- 
ference from  cholera,  carbuncle,  diphtheria,  and  bites  of  serpents, 
in  which  cases  we  do  not  assume  different  natures,  but  only  differ- 
ences of  intensity  and  in  the  quantity  of  poison  absorbed,  and  dif- 
ference of  resisting  power  in  the  patients. 

Some  surgeons  prefer  to  say  that  a  patient  who  has  been  wound- 
ed or  operated  on  has  died  of  severe  typhous  traumatic  fever,  in- 
stead of  using  the  term  "septhsemia"  or  "  septicha?niia."  This  is 
an  incorrect  expression  even  if  it  were  practically  true.  "  Tyj^hous  " 
is  used  in  the  old  sense,  like  the  rvcboq  of  Hippocrates,  for  stupid  ; 
later  the  term  typhous  was  applied  to  fevers  in  wliich  the  patient 
was  stupid  ;  during  the  last  twenty  years  well-characterized  infec- 
tious diseases  have  been  called  "  typhus."  It  is  better  to  use  the 
name  thus,  and  not  bring  the  term  typhous  into  use  again.  Vir- 
choio  uses  "ichorrhjeraia"  in  the  same  sense  that  I  do  septicaemia  ; 
Ixi^p  means  blood-water,  lymph,  serum  of  wounds  ;  the  older  sur- 
geons occasionally  apply  the  term  to  thin,  bad  pus. 

[Since  antiseptic  treatment  of  wounds  is  in  vogue,  septica?mia 
and  pya?mia  are  fortunately  rare  ;  while  the  former  were  common 
even  in  the  best  arranged  hospitals,  now  where  antisepsis  is  common 
months  may  pass  without  a  case,  and  even  this  is  apt  to  occur  in 
patients  infected  before  entering  the  hospital.  Tlie  whole  differ- 
ence between  formerly  and  now  lies  in  the  management  of  the 
wound  and  paying  attention  to  trifles. 

When  the  disease  is  fully  developed  little  can  be  done  for  it.] 

The  cause  of  this  is  said  to  be  that  the  septic  matter,  once  taken 
into  the  blood,  acts  as  a  ferment,  and  that  a  small  quantity  suflices 
to  cause  decomposition  of  the  blood  and  all  the  juices.  As  already 
stated,  I  do  not  consider  this  hrematozymotic  action  of  septic  poison 
as  proved  ;  on  the  contrary,  I  think  that  it,  like  the  i)oison  of  diph- 
theria, malignant  pustule,  etc.,  often  acts  for  so  long  a  time  and  so 
differently,  even  when  taken  up  in  small  quantities,  because  the 
human  organism  (as  well  as  that  of  some  animals)  only  sets  it  free 
very  slowly,  and  because  at  the  points  where  it  is  retained  in  the 
body  it  often  excites  new  foci,  where  the  poison  forms  anew  (per- 
haps less  intense).     For  instance,  I  think  dogs  can  bear  so  much 


SEPTiaEMIA.  419 

septic  poison  because  they  pass  it  off  so  rapidly  by  the  bowels  ;  they 
thus  escape  even  very  severe  putrid  infection.  The  power  of  get- 
ting rid  of  absorbed  infecting  poison  more  or  less  rapidiy  may  vary 
with  the  individual  to  some  extent.  The  same  view  would  hold  in 
typhus,  cholera,  and  the  acute  exanthemata. 

[Many  surgeons  assert  that  pyaemia  often  results  from  a  miasm, 
especially  from  that  developed  by  many  wounded  patients  lying 
together  ;  this  view  is  based  chiefly  on  the  fact  that  where  numer- 
ous severe  surgical  cases  lie  together,  many  of  them  die  of  pyae- 
mia, and  that  even  mild  cases  with  granulating  wounds  become 
pyoemic  under  such  circumstaucas.  I  can  entirely  agree  to  the 
miasmatic  origin  of  pyaemia,  if  by  miasma  is  understood  what  I 
understand  by  it  in  the  present  and  some  other  cases,  namely,  dust- 
like dried  constituents  of  pus,  and  possibly  also  accompanying 
minute  living  very  small  organisms,  which  in  badly-ventilated  sick- 
rooms are  suspended  in  the  air  or  adhere  to  the  walls,  bedclothes, 
dressings,  or  carelessly-cleaned  instruments.  These  bodies,  which 
are  in  some  respects  of  different  natures,  are  usually  phlogogenous, 
all  pyrogenous  when  they  enter  the  blood  ;  of  course  they  will  col- 
lect chiefly  where  there  is  the  best  opportunity  for  their  develop- 
ment and  attachment,  that  is,  in  badly-ventilated  sick-rooms,  where 
the  patients  are  carelessly  attended  and  remain  some  time  in  the 
same  apartments  which  are  not  kept  sufficiently  clean.] 

Another  common  question  is.  Is  pyaemia  contagious?  Accord- 
ing to  the  view  I  have  just  given  of  pyaemic  miasm,  this  is  an- 
swered to  some  extent  both  in  the  affirmative  and  negative.  A  fixed 
molecular  miasm,  originating  from  a  suppurating  pyoemic  patient, 
must  at  the  same  time  be  regarded  as  a  fixed  contagion  ;  but  accord- 
ing to  ray  view  this  miasm  may  just  as  well  come  from  a  non-pyaemic 
patient ;  then  it  cannot  be  termed  contagious  in  a  specific  sense,  for 
a  contagion  always  induces  the  same  disease.  You  see  that  the  strife 
as  to  the  contagiousness  or  non-contagiousness  of  pyaemia  must  go 
back  to  the  views  as  to  the  nature  of  the  disease  ;  it  is  only  impor- 
tant for  those  surgeons  who  regard  pyaemia  as  a  peculiar  specific  dis- 
ease, not  related  to  suppurative  fever — a  view  which  I  regard  as 
groundless  and  practically  useless,  and  against  which  I  have  long- 
fought,  and  I  hope  with  some  success.  With  all  these  things  arises 
the  question,  Does  pycmnic  miasm  enter  the  body  only  through  the 
xoound,  or  also  through  the  shin  and  mucous  m,emhranes  ?  Although 
the  latt'er  is  not  impossible,  I  have  not  yet  made  any  certain  obser- 
vations by  which  such  an  hypothesis  can  be  considered  proved  or 
even  probable  ;  but  from  my  experience  I  hold  to  the  opinion  that 


420  PYEMIA. 

the  infection  of  the  whole  body  comes  from  the  wound,  whether  tlie 
poison  finds  circumstances  favorable  to  its  develojDment  in  the  wound 
and  sv;rrounding  parts,  or  whether  it  be  introduced  into  the  Avound 
already  developed.  I  am  not  shaken  in  this  view  even  by  those  rare 
cases  where  there  is  no  visible  change,  or  only  very  little,  in  the  wound 
on  commencing  jDyffimia,  for  possibly  the  infecting  body  has  very  little 
if  any  phlogogenous  action,  and  hence  may  enter  the  blood  through  the 
wound,  and  have  a  pyrogenous  action,  without  causing  any  change  in 
the  wound  at  its  entrance.  /LSe.x  seems  to  have  very  little  influence  on 
the  frequency  of  infectious  diseases  of  this  class ;  possibly  tempera- 
ment, the  energy  and  frequency  of  the  contractions  of  the  heart  and 
arteries,  may  have  more  influence  on  the  reabsorption  of  the  delete- 
rious substances.  Judging  from  general  impressions,  children  seem 
less  disposed  to  pya?mia  than  adults.  It  would  be  exceedingly  diffi- 
cult to  make  statistics  on  this  point,  as  so  few  severe  injuries  occur  in 
women  and  children  as  compared  with  men  ;  consequently,  the  fact 
that  so  many  more  men  die  of  traumatic-infection  fever  of  course 
proves  nothing  about  the  predisposition  of  eitlier  class  to  this  disease. 
Open  wounds  of  bone  particularly  dispose  to  p3'aemia  ;  judging  from 
mv  experience,  those  wounded  in  the  lower  extremity  are  most,  those 
wounded  in  the  trunk  are  least,  in  danger  of  becoming  pj^j^mic. 
The  time  of  year  and  the  collection  of  severely  wounded  in  hospitals 
seem  to  have  little  if  any  direct  influence  on  the  developjnent  of  py- 
temia,  unless  by  causing  greater  accumulation  of  infecting  matter  in 
the  dressings,  etc.,  thus  increasing  opportunity  for  infection. 

Lastly,  I  must  mention  the  so-called  spontaneous  pyajmia.  Cases 
occur  where  multiple  abscesses  (of  the  subcutaneous  tissue,  for  in- 
stance), or  even  venous  thrombi  with  embolic  metastatic  abscesses,  ap- 
pear without  our  being  able  certainly  to  detect  any  primary  point  of 
suppuration ;  these  cases,  especially  if  they  run  an  acute  course,  are 
called  spontaneous  pyaemia.  There  is  no  reason  for  raising  a  new 
theory  for  these  rare  cases,  where  we  simply  fail  to  detect  the  primary 
point  of  inflammation ;  I  doubt  not  that  there  will  hereafter  be  less 
mention  of  these  cases,  which,  according  to  old  theories,  were  very 
enigmatical,  as  we  are  constantly  learning  to  observe  more  accurately, 
and,  on  more  careful  examination,  sliall  usually  find  the  connection  o' 
the  sym})toms. 

From  the  intimate  relation,  which  we  suppose  to  exist,  between 
traumatic  fever,  septicemia,  and  pj'aemia,  it  seems  correct  to  speak 
of  the  treatment  of  these  diseases  under  the  same  head.  This  may 
be  divided  into  prophylaxis,  and  the  treatment  of  the  developed  dis- 
ease.    The  former  is  by  far  the  most  important ;  it  consists  in  avoid 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC.  421 

mg  every  thing  that  may  favor  the  disease.  Even  in  operations  there 
are  some  points  to  be  observed  ;  all  the  instruments  used,  the  hands 
of  the  operator  and  his  assistants,  and  the  sponges  (which  should 
either  be  perfectly  new  or  should  be  replaced  by  moist  compresses), 
should  be  perfectly  clean ;  haemorrhages  should  be  entirely  arrested, 
especially  if  sutures  are  to  be  applied,  and  the  wound  is  deep ;  if  the 
wound  heals  by  suppuration,  the  compresses  should  be  moistened  with 
chlorine-water.  In  accidental  injuries,  all  deep  wounds,  particularly 
if  contused,  should  be  kept  quiet  by  dressings  ;  all  that  is  necessary 
in  compound  fractures  has  already  been  said.  Every  thing  that  can 
excite  secondary  inflammation  (page  178)  should  be  most  carefully 
avoided ;  the  patient  should  lie  quiet,  and  as  comfortably  as  possible. 
I  would  remind  you  of  the  treatment  previously  given  for  contused 
wounds.  Of  course  the  greatest  care  must  be  used  in  dressing  the 
wound ;  here  the  greatest  j^edantry  may  be  very  beneficial.  Hospital 
influences,  which  I  only  touch  on  here,  are  peculiarly  interesting. 
Although  few  of  you  may  have  the  fortune  to  control  civil  hospitals, 
any  of  you  may  desire  knowledge  on  this  point  during  war.  Of 
course,  hospitals  should  only  be  located  where  there  is  no  marsh 
miasm.  The  hospital  should  be  placed  in  a  large,  open  space,  with 
trees  planted  about  it,  and  should  have  properly-located  odorless  wa- 
ter-closets. Of  all  artificial  systems  of  ventilation,  I  think  that  Van 
Heke's  is  the  only  one  worth  any  thing.  In  it  the  walls  of  the  whole 
building  are  traversed  by  canals,  opening  into  every  ward.  All  these 
canals  start  from  cross-passages  under  the  building,  at  whose  points 
of  intersection  there  is  a  sort  of  wind-mill,  driven  by  steam,  so  that 
new  air  is  thus  constantly  driven  into  the  wards  of  the  hospital  (pul- 
sionssystem).  If  there  be  no  artificial  system  of  ventilation,  we  must 
do  as  well  as  we  can  with  the  so-called  natural  ventilation,  i.  e.,  cor 
responding  draught-openings  should  be  made  above  and  below  in 
doors  and  windows,  so  that  in  their  beds  the  patients  may  escape  the 
draught  as  much  as  possible ;  these  ventilators  should  never  be  en- 
tirely closed.  An  excellent  English  surgeon,  Spencer  Wells,  says : 
"  There  is  only  one  true  means  of  ventilation  :  the  impossibility  of 
closing  doors  and  windows."  I  consider  a  proper  use  of  the  wards 
as  important  as  their  ventilation.  No  surgical  ward  should  be  used 
more  than  four  weeks  in  succession ;  it  should  then  be  emptied  for  a 
few  days  and  carefully  cleaned  ;  the  walls  should  be  painted  "with  oil- 
paint  so  that  they  may  be  washed,  or  else  they  should  be  white- 
washed at  least  two  or  three  times  a  year,  more  frequently  if  neces- 
sary. The  beds  should  be  frequently  aired,  shaken  up,  and  sunned, 
and  the  straw  in  the  sacks  often  renewed.  Every  siu-gical  division 
should  have  one,  or,  still  better,  two  supernumerary  wards,  so   that 


422         TREATMENT  OF  TRAUMATIC  FEVER,  ETC. 

they  may  be  regularly  occupied  in  turns.  With  the  same  object, 
there  should  not  be  more  than  six  or  eight  beds  in  one  ward,  so  that 
enough  patients  may  be  discharged  every  week  to  empty  one  room. 
The  new  patients  should  always  be  brought  into  the  ward  last 
cleaned.  This  is  the  only  way  to  prevent  the  extensive  development 
of  miasm  in  hospital.  To  attain  the  best  possible  results  in  hospital 
we  must  have  plenty  of  room,  and  plenty  of  money  for  nurses,  linen, 
etc.  We  can  thus  use  even  badly-located  hospitals.  Large  wards, 
with  twenty  or  thirty  beds,  which,  from  press  of  patients  and  other 
causes,  cannot  be  emptied  at  will,  are  very  unsuitable.  The  director 
of  a  surgical  division  should,  above  all  things,  have  at  his  disposal  a 
large  number  of  well-ventilated  rooms  of  medium  size,  which  can  be 
emptied  and  cleaned  at  certain  times.  Bad  hospitals,  and  especially 
badly-kept  rooms  for  surgical  patients,  are  worse  than  the  poorest 
tenements  ;  they  may  become  slaughter-pens  for  the  wounded.  Sur- 
geons should  never  forget  that  they  themselves  are  often  to  blame  if 
their  patients  have  erysipelas,  hospital  gangrene,  diphtheria,  etc. ;  for, 
if,  after  old  customs,  we  ascribed  every  thing  to  the  invisible,  omni- 
present, intangible,  ethereal  miasm  and  genus  epidemicus,  it  would  be 
death  to  all  our  future  progress. 

Coming  now  to  the  treatment  of  traumatic  fever,  septicsemia,  and 
pyjBmia,  we  maj'  say  that,  for  simple  traumatic  and  suppurative  fever, 
which  does  not  pass  the  usual  limits,  we  generally  use  nothing  but 
cooling  drinks,  fever  diet,  and  a  little  morphine  at  night  to  secure 
good  rest.  If  the  fever  lasts  longer,  or  assumes  a  peculiar  character, 
we  may  resort  to  febrifuges.  DigitaHs  is  here  of  little  use,  on  account 
of  its  slow,  uncertain  action.  Veratria  reduces  the  temperature,  but 
appears  to  do  little  good  in  toxic  traumatic  fevers  ;  still,  further  obser- 
vations must  be  made  on  this  point,  especially  in  pyaemia.  The  ac- 
curate studies  of  jBiermer  show  that  this  remedy  should  be  used  very 
carefully.  Formerly  aconite  was  highly  recommended  in  pyaemia  by 
Textor.  I  have  seen  no  good  from  it.  Quinine  is  the  most  effica- 
cious remedy  for  the  intermittent  suppurative  fever,  especially  in  com- 
bination with  opium;  6-8-16  grains  of  quinine  in  the  course  of  the 
afternoon,  and  one  grain  of  opium  at  night,  often  arrest  the  chills ;  in 
BCA^ere  suppurative  fevers  I  employ  these  remedies  with  benefit ;  in 
decided  pyremia  they  do  less  good.  After  careful  observation,  Lieher- 
meister  found  that  quinine  only  showed  its  antifebrile  action  in  typhus 
and  other  infectious  diseases  with  certainty  when  given  to  the  exter.t 
of  fifteen  grains  or  more  daily.  There  are  plenty  of  observations,  too, 
on  remedies  for  directly  opposing  the  blood-poisoning.  I  have  found 
no  effect  from  the  antiseptic  internal  remedies,  the  acids,  chlorine-wa- 
ter, and  sulphurets  of  the  alkalies  (which  are  greatly  praised  bv  Polli). 


TRAUMATIC   AND   IXFLAMMATORY   DISEASES,   ETC.  423 

But  we  may  also  use  other  remedies,  intended,  by  increasing  the 
change  of  tissue,  to  separate  the  organic  poison  from  the  blood.  See- 
ing the  profuse  diarrhoea  in  dogs  artificially  made  septicsemic,  and 
finding  them  to  recover  frequently  after  these  diarrhoeas,  we  might 
suppose  the  poison  to  be  most  naturally  excreted  through  the  intes- 
tinal canal.  In  fact,  Breslau  has  had  favorable  results  from  repeated 
doses  of  laxatives  in  puerperal  fever.  I  am  sorry  not  to  have  had 
similar  experience  in  py.iemia.  In  this  disease  diarrhoea  is  a  severe 
complication,  which  quickly  induces  collapse.  It  might  also  be 
thought  advisable  to  increase  the  secretory  actinty  by  giving  emet- 
ics ;  but  they  are  followed  by  such  collapse  that  we  must  be  careful 
in  their  administration.  In  septicsemia  I  have  often  tried  to  induce 
profuse  perspiration,  when  the  skin  was  very  dry.  This  was  occasion- 
ally done  by  a  warm  bath,  lasting  for  an  hour,  and  then  wrapping  in 
blankets.  This  occasionally  does  good  ;  indeed,  I  think  patients  have 
thus  been  saved  that  I  had  thought  incurable.  Further  trials  should  be 
made  with  this  remedy.  Copious  diuresis  also  may  be  induced  by 
plenty  of  drink,  but  it  has  not  much  effect  on  the  general  condition. 
Lastly,  we  might  think  of  arresting  the  further  absorption  of  inju- 
rious substances  from  the  injured  or  inflamed  part  by  amputation, 
even  after  the  appearance  of  severe  constitutional  symptoms.  In 
acute  cases  of  septiccemia  and  pyaemia  this  very  rarely  has  a  perma- 
nently beneficial  effect,  although  there  is  almost  alwaj^s  temporary 
improvement.  But  in  subacute  and  chronic  pytemia  amputation 
may,  indeed,  save  life  ;  imfortunately,  however,  such  cases  are  rare. 

So  we  finally  come  back  to  what  we  said  at  first,  that  much  may 
be  done  to  prevent  severe  traumatic  and  suppurative  fever,  bvit  that 
there  is  little  to  be  hoped  from  treatment  of  these  diseases  Avhen 
fully  developed. 


LECTURE     XXVII. 

4,  Tetanus;  5.  Delirium  Potatorum  Traumaticum;  6.  Delirium  Nervosum  aud  Mania. — 
Appendix  to  Chapter  XUI. — Poisoned  Wounds  ;  Insect-bites,  Snake-bites;  Infec- 
tion from  dissecting  Wounds. — Glanders. — Carbuncle. — Hydrophobia. 

The  group  of  diseases  which  belong  to  the  traumatic  and  phlogistic 
Infectious  conditions,  and  of  which  we  still  have  to  speak,  comprises 
tetanus,  drunkard's  madness,  and  the  psychical  disturbances  Avhich  so 
rarely  occur  after  injuries  and  operations.  The  views,  as  to  their  ori- 
gin,  vary  greatly ;  as,  from  their  symptoms,  the  processes  in  question 
would  be  referred  to  irritation  of  the  brain  and  spinal  cord,  their  cause 


424  TETANUS. 

is  usually  sought  m  the  nervous  centres.  But  it  is  known  that  by 
blood-poisoning,  with  strychnine,  severe  spasms,  and  with  alcohol, 
psychical  disturbances  (drunkenness)  may  be  induced  ;  hence,  it  is 
very  possible  that  the  following  forms  of  disease  may  result  from 
poisoning  Avith  peculiar  substances,  which  possibly  are  ver}^  raiely 
formed  in  wounds,  and  thence  absorbed,  while  in  drunkard's  mania  a 
series  of  ordinary  pyrogenous  materials  may  excite  certain  disturb- 
ances (namely,  fever  with  peculiar,  predominant  psychical  disturbances) 
in  the  organism  already  poisoned  by  alcohol.  The  symptoms  that  we 
shall  see  in  these  diseases  are  all  present  in  ordinary  fever,  although 
to  a  slighter  and  less  prominent  degree ;  in  the  combination  of  the 
aifected  muscles,  chills  have  an  undoubted  similarity  to  tetanus,  psy- 
chical disturbances,  even  to  maniacal  attacks,  occur  as  so-called  fever 
delirium  in  some  cases  of  septicaemia,  but  especially  in  typhus.  In  de- 
scribing the  individual  diseases,  we  shall  occasionally  recur  to  these 
remarks,  for  which,  unfortunately,  we  have  no  experimental  foundation. 

4.  Traumatic  Tetanus  [Trismus). — This  disease,  which  consists  in 
spasms  of  the  muscles  of  the  jaw  alone  (trismus),  or  of  all  the  muscles 
of  the  body  (tetanus),  the  muscles  of  the  extremities  being  most  affected 
sometimes,  at  others  those  of  the  fiont  or  back  of  the  trunk,  occasion- 
ally occurs  in  the  wounded ;  though  it  is  rare  in  proportion  to  the 
traumatic  diseases  above  described,  it  occurs  still  more  rarely  in  per- 
sons without  wounds.  In  large  hospitals,  years  may  pass  without  a 
case  of  tetanus  being  seen;  again,  at  certain  times,  numbers  of  cases 
will  appear,  so  that  there  has  been  an  inclination  to  seek  an  epidemic 
cause.  The  disease  is  by  no  means  confined  to  hospitals,  but  comes 
either  in  or  out  of  them.  However,  before  discussing  the  etiolog}',  I 
will  try  to  give  you  a  brief  description  of  an  acute  case. 

The  third  or  fourth  day  after  an  injury,  rarely  sooner,  often  later, 
you  find  that  the  patient  cannot  open  his  mouth  well  when  speaking, 
and  comjDlains  of  tearing,  drawing  pains,  and  of  stiffness  in  the  masti- 
catory muscles.  In  very  acute  cases  there  is  high  fever  even  with 
these  first  symptoms,  in  other  cases  the  patient  is  free  from  fever  at 
this  stage.  The  lines  in  the  patient's  face  gradually  assume  a  pecu- 
liar, stiff  expression,  the  facial  muscles  being  to  some  extent  spasmod- 
ically contracted.  Subsequently  there  are  tetanic  spasms,  which  may 
affect  the  trunk  or  extremities ;  in  some  cases  these  last  several  sec- 
onds or  minutes,  and  are  induced  by  any  external  imtation,  just  as  in 
hydrophobia.  These  spasms  are  accompanied  by  severe  pain.  Occa- 
sionally, from  first  to  last,  some  groups  of  muscles  remain  regularly 
but  painlessly  contracted ;  in  some  jDatients  the  twitchings  (shocks 
of  Hose)  are  entirely  absent,  and  there  is  only  permanent  contraction 
of  more  or  less  distinct  gToups  of  muscles.     Not  unfrequently  the 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,   ETC.  405 

patient's  body  is  bathed  in  sweat,  his  mind  being  clear ;  occasionally  the 
urine  contains  albumen ;  sometimes  the  fever  rises  to  a  height  that 
is  rai-ely  seen,  even  to  104°  Fahr.,  or  over.  But  I  have  seen  cases 
of  trismus  prove  rapidly  fatal,  without  the  temperature  becoming  ele- 
vated ;  Mose  has  made  similar  observations.  Death  may  occur  within 
twenty-four  hours  from  the  commencement  of  the  disease,  but  the  lat- 
ter may  also  last  with  considerable  severity  for  three  or  four  days  ; 
these  cases  also  are  to  be  classed  among  the  acute.  There  is  a  more 
subacute  or  chronic  form  of  trismus,  and  of  trismus  and  tetanus,  in 
which  there  is  merely  a  gradual  development  of  a  moderate  trismus 
and  of  contractions  withovit  pain,  extending  to  single  groups  of  mus- 
cles of  the  injured  limb.  In  these  chronic  cases  fever  is  usually  en- 
tii-ely  absent.     It  is  rare  for  an  acute  case  to  become  chronic. 

All  the  symptoms  indicate  that  there  is  an  irritation  of  the  spinal 
medulla  and  of  the  portio  minor  of  the  fifth  pair.  The  symptoms  re- 
semble, although  remotely,  those  which  may  be  induced  by  poisoning 
by  strychnia.  Unfortunately,  the  results  given  by  autopsy  of  these 
patients  are  usually  very  unsatisfactory ;  in  the  acute  cases,  especially, 
nothing  can  be  found  in  the  spinal  medulla ;  in  cases  of  some  days' 
duration,  HoJcitansky  claims  to  have  seen  a  development  of  young 
connective  tissue  in  the  spinal  medulla,  which  would  make  it  appear 
that  there  was  an  inflammatory  affection  of  this  nerve-centre.  My  ex- 
aminations of  the  spine  and  nerves  in  tetanus  have  thus  far  given  only 
negative  results.  In  preparations  made  from  cross-sections  of  the 
spinal  medulla,  and  sent  to  me  by  excellent  specialists  in  examining 
the  nervous  system  (Dr.  Goll^  in  Zurich,  and  Dr.  Meynert^  in  Vienna), 
I  saw  the  connective  tissue  remarkably  developed  at  some  places,  it  is 
true ;  but,  as  there  was  no  collection  of  young  cells,  I  was  in  doubt 
whether  this  increase  of  connective  tissue  was  really  new  formation, 
or  was  due  to  mere  accidental  swelling.  The  symptoms  during  life, 
in  cases  where  we  find  decided  evidences  of  spinal  inflammation,  are 
so  different  from  tetanus  as  to  render  it  improbable  that  the  latter  de- 
pends on  myelitis  spinalis.  The  discovery  of  small  extravasations  of 
blood  in  the  muscles  and  nerve-sheaths,  on  autopsy,  shows  little  about 
the  nature  of  the  disease,  for  they  may  be  caused  by  ruptures  of  the 
capillaries  during  the  great  muscular  contractions. 

There  are  many  views  as  to  the  causes  of  this  disease,  as  there 
usually  are  about  affections  with  no  anatomical,  pathological  charac- 
teristics. At  first,  it  was  natural  to  examine  the  nerves,  and  in  many 
eases  the  nerve-trunks  are  crushed  by  the  injury,  or  torn  or  irritated 
by  foreign  bodies.  I  myself  have  seen  some  such  cases  ;  a  few  years 
since,  I  saw  a  sporadic  case  where,  in  an  open  splintered  fracture  of  tlie 
lower  end  of  the  radius,  the  median  nerve  was  half  torn  through;  the 


426  TETAlsTTS. 

third  day  trismus  ana  tetanus  appeared  suddenly,  and  proved  fatal  in 
eighteen  hours.  It  is  no  use  to  build  theories  as  to  how  this  particu- 
lar variety  of  injury  of  the  nerves  should  induce  tetanic  spasms,  whilf 
they  are  very  rare  after  simple  division  of  the  nerves,  for  there  aro 
many  cases  where  tetanus  has  arisen  from  simple  wounds  of  the  skin, 
from  granulating  surfaces  fully  developed  and  cicatrizing,  or  even 
after  a  blister,  the  sting  of  a  bee,  etc.  It  is,  however,  remarkable  that 
the  disease  is  particularly  frequent  after  injuries  of  the  extremities, 
especially  of  the  hands  and  feet,  while  it  is  rare  after  considerable 
injuries  higher  up  the  limb  and  on  the  body.  I  also  think  that  I  have 
found  the  cases,  where  tetanus  developed  from  granulating  wounds,  to 
be  more  chronic  and  milder  than  those  where  it  has  developed  soon 
after  the  injury.  Hose  thinks  that  tetanus  appears  particularly  in 
cases  that  are  treated  badly  or  not  at  all ;  my  experience  is  opposed 
to  this.  After  applying  in  vain  to  the  nerves  and  tendinous  tissue, 
the  various  changes  of  temperature  were  resorted  to  to  explain  the 
occurrence  of  tetanus;  some  said  that  it  was  favored  by  hot,  sultry 
weather.  I  cannot  altogether  deny  this  view,  for  hitherto  I  have  only 
seen  numerous  cases  of  traumatic  tetanus  in  hot,  sultry  weather,  but 
small  epidemics  of  it  have  been  seen  in  winte^.  Others  ascribe  the 
chief  blame  to  catching  cold  from  draughts  or  to  rapid  changes  of  tem- 
perature. Finally,  there  are  still  others  who  do  not  believe  that  the 
nervous  system  is  primarily  affected,  but  think  that  the  blood  first 
becomes  diseased  and  acts  secondarily  on  the  nervous  system.  Within 
a  short  time  Hose  has  resurrected  an  old  idea,  that  tetanus,  like  hydro- 
phobia, is  to  be  regarded  as  a  primary  blood-disease.  It  cannot  be 
denied  that  the  two  diseases  are  much  alike ;  a  proof  of  their  being 
actually  analogous  would  be  most  strikingly  given  by  inducing  hydro- 
phobia, by  inoculating  animals  with  the  blood  or  secretions  from  a 
tetanus  patient.  Of  course,  we  should  not  think  of  inoculating  another 
man.  At  present,  I  strongly  incline  to  the  humoral  view  of  tetanus 
as  due  to  a  peculiar  poison,  although  I  have  no  proofs  of  it.  At  all 
events,  the  blood  of  a  tetanus  patient  should  be  injected  into  a  dog, 
to  show  whether  tetanus  may  be  transferred  through  human  blood  to 
a  dog,  and  also  whether  it  has  a  pyrogenous  action ;  should  tetanus 
appear  in  the  dog,  it  might  be  regarded  as  proved  that  tetanus  was  a 
humoral  disease ;  if  the  experiment  be  negative,  it  prov^es  nothing 
against  the  humoral  causes  of  tetanus,  it  only  shows  that  the  blood  of 
a  7nan  with  tetanus  will  not  induce  tetanus  in  a  dog  •  it  would  still 
have  to  be  decided  whether  the  blood  of  a  dog  with  tetanus,  trans- 
ferred to  another  dog,  would  prove  as  inactive.  Tiie  fact  that  tetanus 
may  be  confined  to  one  limb,  or  even  to  one  hand  as  I  have  seen  it, 
Bpeaks  in  favor  of  a  local  cause,  which  may  be  limited  to  the  nerves ; 


TRAUMATIC   AXD  IXFLAMMATORY   DISEASES,   ETC.  427 

but  there  are  also  a  localized  lymphangitis,  localized  erysipelas,  etc. : 
the  fact  that,  after  amputation,  for  instance,  twitching  not  unfrequently 
occurs  in  the  stump  before  the  spasms  become  general,  might  also 
indicate  that  the  tetanus-poison  formed  in  the  wound  first  irritated 
the  muscles  and  nerves  of  the  stump,  and  then  passed  to  the  spinal 
medulla.  There  still  remains  much  to  be  investigated  on  this  point. 
The  high  fever  in  most  cases  of  acute  tetanus,  and  the  fact  that  the 
temperature  rises  even  after  their  death,  has  greatly  occupied  pathol- 
ogists ;  this  became  still  more  interesting  when  Leyden  showed  that 
great  elevation  of  the  temperature  of  the  blood  was  caused  in  a  dog 
in  which  tetanus  had  been  artificially  induced  b}^  passing  a  strong 
current  of  electricity  through  the  whole  spinal  medulla.  A.  Fick 
showed  that  a  sur[)lus  of  heat  was  formed  in  the  muscles,  and  thence 
distributed  to  the  blood ;  also  that  the  elevation  of  temperature,  noticed 
in  the  rectum  after  death,  was  due  to  the  equalization  of  warmth 
between  the  muscles  and  the  rest  of  the  body.  If  these  experiments, 
which  I  have  repeated,  prove  that  tetanic  muscular  contractions  con- 
siderably elevate  the  bodily  temperature,  they  do  not  show  that  in 
traumatic  tetanus  in  man  the  high  temperature  is  solely  or  chiefly 
due  to  the  muscular  contractions ;  this  view  is  opposed  by  the  fact 
that  very  acute  cases  of  tetanus  may  run  their  course  almost  without 
fever,  although  this  rarely  happens ;  here,  too,  there  are  many  enigmas 
to  solve. 

Unfortunately,  in  most  cases  the  prognosis  is  bad ;  very  few  of 
the  acute  cases  recover ;  of  the  chronic  cases,  which  last  over  a  fort- 
night, some  get  well.  Unfortunately,  the  latter  are  proportionately 
rare. 

From  the  lack  of  knowledge  about  the  etiology  of  this  disease,  the 
treatment  can  be  only  symptomatic.  Numerous  remedies  have  been 
recommended  at  various  times.  Generally,  the  treatment  most  resorted 
to  is  by  narcotics,  with  opium  and  chloroform ;  this  is  the  plan  I  have 
adopted.  Opium  is  given  in  large  doses,  as  high  as  fifteen  grains  or 
more  in  a  day,  or  a  corresponding  quantity  of  morphine  may  be  given, 
best  by  subcutaneous  injection ;  sometimes  this  aiTests  the  spasms, 
sometimes  it  does  no  good.  At  all  events,  the  snflPerings  of  the  pa- 
tient are  lessened.  During  the  attacks  the  patient  may  be  greatly 
relieved  by  inhaling  chloroform  to  narcotism.  Under  this  treatment 
many  cases  have  recovered.  The  general  aim  of  the  treatment  is  to 
alleviate  the  acute  course,  and  make  it  more  chronic,  as  tliis  gives 
more  hope  of  recovery.  Among  other  modes  of  treatment,  I  may 
mention  the  frequent  emjiloyment  of  warm  potash-baths ;  and  the 
application  of  strong  irritants  along  the  spine,  large  blisters,  moxae. 
the  hot-iron,  remedies  from  which  I  cannot  promise  any  good  eflects , 


428  DELIRIUM   TREMENS. 

and,  lastly,  the  curare,  which  is  of  late  occasionally  used,  has  not 
answered  the  hopes  that  some  had  of  it. 

In  the  chronic  cases  you  need  not  employ  any  special  treatment ; 
the  patient  remains  in  bed,  and  should  keep  perfectly  quiet ;  he  should 
be  guarded  against  all  injurious  influences,  especially  from  phj'sical 
or  mental  excitement. 

5.  DrunJcard^s  madness.  Delirium  2^otatorum  tramnaticiim. 
■Delirium  treinens. — We  noAv  come  to  an  enemy  of  the  wounded 
which,  fortunatel}^  is  not  very  dangerous.  You  have  doubtless  heard 
of  delirium  tremens,  the  acute  outbreak  of  chronic  alcoholic  poisoning, 
which  may  come  on  spontaneously,  or  from  some  acute  diseases,  es- 
pecially pneumonia.  Injuries  are  a  frequent  cause.  You  will  become 
better  acquainted  Avith  this  disease  from  the  lectures  on  medicine ;  as 
the  attacks,  from  Avhatever  cause  they  arise,  are  much  alike,  I  shall 
be  very  brief  on  this  point. 

The  disease  generally  breaks  out  within  two  days  after  the  injury, 
in  some  rare  cases  it  is  longer.  It  only  attacks  patients  who  have  for 
years  been  accustomed  to  the  free  use  of  alcohol,  especially  of  schnaps 
and  rum  ;  but  it  is  an  error  to  consider  beer  and  wine  drinkers  exempt 
from  delirium.  The  first  symptoms  are  sleeplessness,  great  restless- 
ness, trembling  hands,  unsteady  look,  tossing  about  in  bed,  and  talka- 
tiveness, and  then  delirium.  The  patients  talk  constantly,  see  small 
animals,  midges,  flies,  etc.,  swarming  about  them ;  mice,  rats,  mar- 
tins, foxes,  etc.,  crawl  from  under  their  beds ;  they  think  they  are  in 
a  smoky  atmosphere,  and  feel  dizzy.  The  delirium  often  has  the 
most  comical  form  ;  a  soldier,  whom  I  treated  in  Zurich  for  delirium 
tremens,  saw  numbers  of  other  soldiers  in  his  water-glass ;  when  I 
entered  the  room,  he  spoke  lowly  to  my  assistant,  taking  me  for  his 
major,  etc.  Generally  the  hallucinations  are  of  a  hajipy  nature,  never- 
theless, the  patients  are  tormented  with  restlessness,  constantly  toss 
about  in  bed,  and  wish  to  get  up.  If  we  have  not  two  stout  nurses 
to  hold  these  patients,  there  is  often  no  way  of  avoiding  the  applica- 
tion of  a  strait-jacket  and  tying  them  in  bed.  These  patients  are 
usually  good-natured  in  their  delirium,  and  if  spoken  to  emphatically 
they  give  sensible  answers,  but  soon  fall  back  into  their  wanderings. 
Of  all  kinds  of  injuries,  fractures,  especially  open  fractures,  most  fre- 
quently give  rise  to  the  outbreak  of  the  disease,  and,  before  we  had 
firm  dressings  for  such  patients,  it  was  a  diflScult  task  to  fix  the  broken 
limb,  as  the  patients  did  not  notice  the  pain,  and  moved  the  limb  so 
forcibly  that  anj'  splints  were  loosened  in  a  few  hours.  Even  where 
there  is  marked  delirium,  the  prognosis  is  not  unfavorable,  according 
to  most  surgeons ;  from  my  somewhat  meagre  observations,  I  cannot 
agree  in  this  opinion :  of  the  patients  with  acute  delirium  tremens  that 


TRAUMATIC  AND   INFLAMMATORY   DISEASES,   ETC.  429 

I  have  treated,  at  least  the  half  have  died  ;  they  often  declined  suddenly, 
became  unconscious,  and  soon  died.  Others  recovered,  especially  when 
it  was  possible  to  make  them  sleep  a  while ;  this  is  the  object  of  the 
treatment ;  opium  in  large  doses  is  the  almost  universal  remedy,  for 
it  we  may  substitute  small  doses  of  tartar-emetic.  After  this  the 
patients  fall  into  a  comatose  state,  from  which  in  favorable  cases  they 
awake  cured,  but  sometimes  sleep  on  till  death.  I  can  recommend  no 
better  remedy  than  opium  in  delirium  tremens,  altliough  I  must  ac- 
knowledge that  in  large  doses  (gr.  ii. — vi,  every  two  hours  till  sleep  is 
induced),  I  do  not  consider  it  free  from  danger  [of  late,  hydrate  of 
chloral,  in  doses  of  gr.  xx. —  3  i,  is  said  to  have  been  given  with  great 
benefit  in  such  cases  ;  it  is  claimed  that  it  acts  well  not  only  on  the 
delirium  tremens,  but  on  the  fever  which  so  often  accompanies  the  in- 
jury]. Of  late,  there  has  been  a  great  outcry  in  England  against  the 
opium  and  tartar-emetic  treatment,  and  a  more  expectant  treatment 
has  been  recommended.  Others  have  had  good  results  from  digitalis  ; 
most  surgeons  are  well  satisfied  with  the  opium-treatment,  and  the 
coincident  administration  of  strong  wine  and  cognac  has  been  highly 
recommended.  The  more  chronic  cases  of  delirium  potatorum,  with- 
out maniacal  attacks,  have  seemed  to  me  of  more  favorable  prognosis; 
there,  strong  grog  is  useful ;  I  give  the  following  mixture :  one  yolk 
of  egg,  one  ounce  of  arrack,  four  ounces  of  water,  two  ounces  of  sugar; 
this  does  not  taste  badl}',  and  may  also  be  used  as  a  stimulant  for  old 
persons  (a  tablespoonful  every  two  hours).  I  must  warn  j^ou  against 
abstracting  blood,  Avhich  is  very  dangerous  in  drunkards,  and  not  un- 
frequently  induces  collapse  terminating  in  death. 

Autopsy  of  patients  who  have  died  of  delirium  tremens  shows  no 
special  cause  of  death ;  we  find  the  changes  common  to  topers ; 
chronic  gastric  catarrh,  fatty  liver,  Bright's  kidneys,  thickening  of  the 
meninges  of  the  brain,  but  no  constant  changes  in  the  brain-substance 
proper. 

6.  Delirium  nervosum  and  psychical  disturbances  after  injury. — 
By  delirium  nervosurn  traumaticxim  we  mean  a  state  of  excessive 
nervous  exaltation  without  fever,  occurring  after  injury ;  this  is  said 
particularly  to  affect  hj'sterical  persons.  I  have  only  seen  one  case  to 
which  I  could  apply  this  name :  a  man  twenty-four  years  old  (from 
Canton  Thurgau,  the  land  of  perry),  who  had  never  been  accustomed 
to  drinking,  after  a  fracture  of  the  leg,  complicated  with  a  slight 
Vv'ound,  soon  had  delirium  without  fever,  like  an  old  toper ;  the  fan- 
cies referred  to  the  same  subjects  as  in  delirium  potatorum,  passed 
off  under  quieting  treatment  and  opium,  without  maniacal  attacks ; 
after  four  days  the  delirium  ceased,  and  the  patient  remained  reason- 
able.    Lastly,  I  must  mention  those  rare  and  interesting  cases  whei'e, 


430  POISONED  WOUNDS. 

after  operations  in  otherudse  healthy  persons,  psychical  disturbances 
develop,  cases  which  evade  all  attempts  at  explanation,  and  are  only 
analogous  to  cases  where,  after  acute  diseases,  such  as  pneumonia, 
acute  rheumatism,  or  typhus,  the  development  of  true  mania  is  ob- 
served. In  the  Berlin  surgical  clinic  I  saw  two  such  cases,  in  both 
of  which,  after  total  rhinoplasty,  there  was  nielancholy  w'ith  religious 
hallucinations.  Both  patients  Avere  Catholic :  one,  a  j'oung  man,  in- 
cessantly worried  himself  trying  to  understand  the  idea  of  the  Trinity- ; 
the  other  patient,  a  young  Avoman,  sought  by  prayers  and  castigations 
to  atone  for  gi\'ing  way  to  her  vanity  so  far  as  to  have  a  new  nose 
made  to  replace  the  one  lost  by  lupus.  In  the  young  man  there  were 
frequent  outbursts  of  rage  ;  both  patients  perfectly  recovered  after  a 
few  weeks.  I  have  heard  that  Von  Langenheck^  in  Berlin,  had  an- 
other such  case  after  a  plastic  operation,  and  Von  Grafe  and  Es- 
march  have  had  them  after  operations  on  the  eyes.  But  these  cases 
are  very  rare. 


APPENDIX   TO   CHAPTER   XIIL 


POISONED  WOUNDS. 


"SVe  have  still  to  treat  of  some  varieties  ot  injuries,  where  at  the 
time  of  the  injury  poison  is  inoculated,  which  sometimes  induces 
severe  local  symptoms,  sometimes  dangerous  general  disease.  It  is 
well  knoW'U  that  these  poisons  are  peculiar  to  some  animals,  and  in 
others  they  develop  as  a  result  of  certain  diseases,  and  are  then  trans- 
ferred by  the  diseased  animal  to  man. 

The  results  from  punctures  of  a  large  number  of  small  insects  are 
scarcely  in  proportion  to  the  slight  mechanical  irritation  caused  by  their 
stings;  it  may,  it  is  true,  depend  partly  on  peculiar  susceptibility  of  the 
skin,  if  persons  have  extensive  temporary  inflammations  of  the  skin  after 
bites  by  bugs,  midges,  or  fleas,  w^hile  others  are  not  affected  by  them. 
A  needle-puncture  is  a  much  greater  injury  than  a  flea-bite,  but  the 
latter  is  followed  by  itching  and  burning,  and  the  formation  of  wheals 
on  the  skin,  while  the  results  of  the  former  amount  to  nothing.  Hence 
it  is  not  improbable  that  in  the  case  of  the  wound  made  by  the  insect 
some  irritating  substance  enters  the  skin.  As  is  known,  the  stings  of 
bees  and  wasps  excite  even  greater  disturbances ;  occasionally  there 
is  an  extensive,  very  painful  inflammation  of  the  skin,  with  great  red- 
ness and  swelling,  which  usually  terminates  in  resolution,  and  does 
not  prove  dangerous,  but  may  be  very  annoying.  A  large  number  of 
such  stings  at  the  same  time  is  not  altogether  free  from  danger ;  such 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC.  431 

stings  on  the  tongue,  in  the  palate,  or  on  the  eyelids,  may  from  their 
locality  cause  certain  dangers  by  the  swelling  induced.  But,  as  these 
inflammations  subside  in  a  relatively  short  time,  a  physician  is  rarely 
called ;  the  popular  treatment  is  by  various  cooling  remedies  to  alle\d- 
ate  the  pain,  among  which  I  shall  merely  mention  the  application  of 
moist  clay,  raw  mashed  potato,  cabbage-leaves,  etc.  In  more  severe 
inflammations,  lotions  of  lead- water  and  other  antiphlogistic  remedies 
may  be  resorted  to.  Still  more  severe  than  the  stings  of  bees  and 
wasps  are  those  from  tarantulce  and  scorpions^  that  are  seen  in  southern 
countries.  They  are  followed  by  more  extensive  inflammation  of  the  skin, 
with  severe  burning  pains,  occasionally  by  formation  of  vesicles ;  there 
may  also  be  fever,  but  there  is  usually  no  danger,  unless  it  arise  from 
the  locality  of  the  injury.  The  treatment  should  be  that  above  given. 
Fortunately,  with  us  there  are  few  varieties  oi  jyoisonoKS  ser2'>e7its^ 
and  even  they  are  not  frequent.  Among  them  are  the  Vij^era  Jierus 
(cross  adder),  and  Vipera  Redii^  with  two  hook-like,  curved  fangs, 
containing  the  excretory  ducts  of  small  glands,  which,  at  the  time 
of  the  bite,  pour  their  poison  into  the  wound.  The  bite  of  these  ser- 
pents is  not  so  dangerous  as  is  supposed;  according  to  statistics, 
about  two  die  out  of  sixty  persons  bitten.  The  pain  is  very  severe ; 
there  are  great  inflammation,  tension  and  swelling  of  the  skin,  with 
high  fever,  great  anxiety,  depression,  vomiting,  and  occasionally 
slight  icterus.  The  best  treatment  is  to  suck  out  the  wound  at  once, 
as  the  poison  is  not  absorbed  by  the  gastric  or  oral  mucous  membrane. 
The  wound  should  be  washed  at  once,  and  it  is  advised  to  Hgate  the 
injured  limb  above  the  wound  to  prevent  the  absorption  of  the  poison; 
but  this  has  usually  taken  place  by  the  time  the  patient  reaches  the 
surgeon ;  it  is  a  disputed  point  whether  the  application  of  cups,  the 
cauterization,  burning  or  excision  of  the  wound,  be  now  of  any  ser- 
vice, but  I  should  think  its  cauterization  adxdsable.  The  local  cutane- 
ous inflammation  is  treated  with  special  attention  to  the  intense  pain ; 
by  applications  of  oil,  protecting  the  skin  from  the  air  by  various  rem- 
edies, with  which  we  become  acquainted  in  the  treatment  of  superfi- 
cial burns.  Internally  we  usually  give  an  emetic,  then  antiseptic 
remedies.  Of  all  snake-bites  in  southern  countries,  those  of  the  rattle- 
snake are  most  dangerous  ;  sometimes  they  prove  fatal  in  a  few  hours ; 
the  local  inflammation  of  the  skin,  which  is  very  severe  and  extensive, 
not  unfrequently  ends  in  gangrene  ;  those  bitten  die  with  high  fever, 
delirium,  and  sopor.  [Prof.  Halford,  of  Australia,  treats  snake-bites 
by  injecting  diluted  liquor  ammonise  into  the  veins.  See  London 
Medical  Times  and  Gazette^  1869,  page  123.] 

Cadaveric  poison  is  a  very  phlogogenous  substance,  which  proba- 
bly varies  greatly  in  its  chemical  composition.     Some  of  you  may  have 


432  POISONED  WOUNDS. 

already  bad  some  experience  on  this  point,  in  the  dissecting-rooma 
This  putrid  poison  dev'elops  in  the  corpses  of  men  and  animals ;  if,  in 
handling  these,  some  of  the  juice  from  the  dead  tissue  enters  small, 
insignificant,  and  scarcely  noticeable  injuries  of  the  skin,  very  dis- 
agreeable symptoms  may  develop.  The  resulting  conditions  are  vari- 
ous, sometimes  very  malignant.  Cases  occur  which  were  formerly 
seen  particularly  often  in  England,  where  at  first  there  is  little  pain  in 
the  wound,  but  there  are  great  depression,  headache,  fever,  and  nausea ; 
then  come  delirium  and  sopor,  and  in  some  cases  death  takes  jolace  in 
forty  hours.  It  is  asserted  tliat  these  worst  cases  of  septicjemia  were 
most  frequent,  from  autojDsies  made  soon  after  death,  on  bodies  still 
warm,  and  it  was  doubtful  if  in  these  cases  the  surgeon  had  not  inoc- 
ulated himself  with  morbid  matter  developed  in  the  body  while  still 
living,  for  the  state  usually  termed  putrefaction  could  not  have  begun. 
As  a  contrast  to  this  malignant  acute  form,  Ave  ma}^  regard  those  cases 
where  the  poison  has  a  purely  local  action.  In  the  course  of  twent}^- 
four  hours  there  are  moderate  pain  and  slight  induration  in  the  injured 
finger;  then  a  dry  scab  forms  on  the  wound;  under  it  there  is  always 
some  pus.  The  scab  forms  as  often  as  it  is  removed,  the  part  remains 
painful  and  hard ;  in  the  course  of  time  the  epidermis  thickens  over  it, 
and  it  forms  a  painful,  wart-like  nodule,  moist  on  the  surface.  One  in- 
clined to  this  purely  local  development  is  usually  less  disposed  to 
general  infection.  Between  these  two  forms  stands  a  third,  where  an 
inflammation  of  the  lymphatic  vessels  and  axillary  glands  accompanies 
the  local  inflammation;  under  earl}^  treatment  this  may  end  in  resolu- 
tion, but  it  often  leads  to  abscesses  in  the  arm. 

For  the  first  treatment  of  the  part  poisoned  by  cadaveric  matter, 
I  advise  you  to  let  cold  water  run  on  the  wound  for  a  long  time,  and 
not  to  check  the  bleeding,  if  there  be  any.  In  many  cases  the  injurious 
matter  will  be  at  once  washed  out,  and  there  will  be  no  further  infec- 
tion. Should  the  parts  around  the  wound  redden,  you  may  cauterize 
with  nitrate  of  silver  or  fuming  nitric  acid ;  this  is  very  painful,  but  it 
acts  well ;  not  unfrequently  pus  forms  again  under  the  resulting  slough ; 
in  this  case  you  remove  the  slough,  and  cauterize  again,  and  repeat  this 
till  no  pus  forms  under  the  slough. 

Cauterization  immediately  after  contact  with  the  poison,  from  a 
considerable  experience  on  mj-self  and  on  my  students  in  the  course 
on  operations,  I  consider  imadvisable.  Small, lacerated  wounds  that 
do  not  bleed,  and  excoriations,  are  always  more  dangerous  for  infec- 
tion than  deeper  incised  wounds ;  the  anatomical  reason  for  this  is 
that  the  lymphatic  net-work  lies  chiefly  in  the  most  superficial  layer 
of  the  cutis.  Moreover,  the  susceptibility  to  the  poison  varies  with 
tiie  indi^adual ;  repeated  infections  appear  rather  to  increase  than  to 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC.  433 

diminish  the  predisposition.  Should  lymphangitis  begin,  tlie  arm 
should  first  of  all  be  placed  on  a  splint  to  keep  it  quiet,  and  then  the 
treatment  previously  recommended  for  lymphangitis  instituted.  You 
may  consider  the  course  in  the  appearance  of  the  above  morbid  symp- 
toms to  be  as  follows  :  A  small  quantity  of  liquid  from  the  cadaver 
(or  even  of  putrid  pus  from  a  living  patient)  is  introduced  into  the 
Avound  ;  the  lymphatic  capillaries  that  have  been  opened  take  up  this 
putrid  matter  and  pass  it  into  the  trunks  of  the  lymphatic  vessels ; 
coagulation  may  quickly  take  place  here,  and  then  the  putrid  matter 
acts  as  a  specific  irritant  only  on  a  small  part ;  in  other  cases  it  acts 
on  the  lymph  as  a  ferment,  and  the  lymph  coagulates  in  the  next 
lymphatic  glands,  or  else  the  swelling  of  the  gland  compresses  the 
intra-glandular  lymphatic  vessels  and  so  obstructs  the  passage 
through  the  gland ;  in  this  case  also  the  disease  remains  local,  al- 
though extending  some  distance,  and  not  unfrequently  leading  to 
suppuration  with  fever  (as  in  other  non-specific  inflammations). 
Lastly,  the  rarest  cases :  the  fermented  lymph,  which  even  yet  acts 
as  a  ferment,  passes  into  the  blood,  and  there  excites  chemical 
changes.  Then  we  have  a  septicoemia,  froni  cadaveric  poison.  From 
the  cases  that  end  in  recovery  we  see  that  the  injurious  substances 
developed  by  the  process  may  be  again  eliminated  from  the  body  b}'' 
the  secretions  and  excretions,  but  we  do  not  know  in  what  particu- 
lar way  this  is  done.  In  some  cases  some  putrid  substance  is  encap- 
sulated in  a  lymphatic  gland  or  other  inflamed  part,  and  may  there 
lie  harmless  and  after  a  time  be  gradually  eliminated ;  but  on  active 
movement  the  poison  may  be  again  driven  into  the  lymphatic  vessels 
by  the  increased  pressure  of  the  blood,  and  there  induce  new,  acute, 
local,  and  general  infection.  If  indurated  lymphatic  glands  remain 
after  infection  with  cadaveric  poison,  daily  warm  baths  are  the  best 
means  for  promoting  the  excretion  of  the  poison. 


We  have  still  to  treat  of  some  poisons  which  in  certain  diseases 
develop  iu  animals,  and  may  thence  be  transferred  to  man.  ,  Under 
this  head  come  glanders^  carbuncle,  and  hydrophobia. 

Glanders  (maliasmus,  morve)  is  a  disease  which  develops  prima- 
rily in  horses  and  asses.  It  is  an  inflammation  of  the  nasal  mucous 
membrane,  in  which  this  membrane  becomes  very  thick,  and  secretes 
a  thick,  tough  pus,  and  where,  by  the  breaking  down  of  caseous  nod- 
ules, ulcers  with  a  caseous  base  form ;  swellings  of  the  lymphatic 
glands,  occasionally  tubercle-like  nodules  in  the  lungs,  and  acute  ma- 
rasmus, occur,  and  acute  cases  are  usually  fatal.  The  more  chronic  and 
milder  form  of  glanders  is  called  "  farcy ;  "  it  is  rarer,  and  gives  a 
29 


434  CARBUNCLE. 

better  prognosis.  The  glanders  and  farcy  of  animals  are  only  con- 
veyed to  man  by  accidental  inoculation.  If  some  of  the  pus  of  a  glan- 
dered  horse  enters  a  wound  or  excoriated  spot  on  a  man,  or  if  very  in- 
tense poisonous  glander-pus  fall  on  the  uninjured  skin  at  a  point  where 
the  epidermis  is  thin,  there  may  be  very  acute  inflammation  with  gen- 
eral septicgemia,  which  in  most  cases  proves  fatal.  The  chronic  form 
of  glanders  is  rare  in  man ;  the  symptoms  are  chiefly  pustulous  inflam- 
mations of  the  skin,  and  formation  of  abscesses  at  different  points  in 
the  subcutaneous  tissue ;  it  is  not  so  dangerous.  In  some  cases  of 
acute  glander-poisoning  there  is  Ijonphangitis  and  suppuration,  limited 
to  the  injured  extremity ;  in  others  a  diffuse  erysipelatous  redness  of 
the  skin  with  great  swelling  develops  quickl}^,  while  at  the  same 
time  there  is  very  intense  fever.  The  local  inflammation  may  go  on 
to  gangrene ;  there  is  delirium,  and  soon  coma  occurs ;  there  may 
also  be  diarrhoea,  purulent  discharge  from  the  nose,  and  pain  in  the 
.muscles,  with  which  symptoms  the  patient  dies.  The  disease  may 
run  its  course  very  rapidly ;  I  remember,  when  a  student  in  the  Got- 
tingen  clinic,  seeing  a  strong,  robust  man  die  of  glanders  in  a  few 
days ;  but  patients  Avith  acute  glanders  may  live  from  ten  to  fourteen 
days,  and  all  the  symptoms  of  pyaemia  may  develop  in  them,  and  nu- 
merous heemorrhagic  abscesses  form  in  the  muscles,  which  are  so 
characteristic  of  glanders  that  they  confirm  the  diagnosis.  In  rare 
cases  acute,  rapidly-fatal  glanders  may  develop  from  the  chronic; 
the  reverse  is  also  seen.  Of  course,  persons  that  have  much  to  do 
vnth  horses  are  chiefly  exposed  to  this  disease,  wbich  never  occurs 
primarily  in  man.  Unfortunately,  there  is  little  hope  from  treatment 
in  this  disease ;  as  in  acute  pyaemia,  we  treat  the  most  prominent 
symptoms.  Iodine,  arsenic,  and  creosote,  have  been  recommended  as 
antidotes  in  glanders. 

Carbuncle  (anthrax,  pustula  maligna)  is  an  infectious  disease  oc- 
curring primarily  most  often  in  cattle.  It  is  called  in  German 
"  Milzbrand  "  (gangrene  of  spleen),  because  in  animals  that  have 
died  of  it  the  spleen  is  found  greatly  swollen,  dark  red,  and  gangre- 
nous ;  in  many  cases  also  the  intestinal  mucous  membrane  is  bloody- 
red  and  swollen  ;  the  loose  subperitoneal  cellular  tissue,  and  occa- 
sionally the  subcutaneous  cellular  tissue,  of  one  of  the  limbs  is  often 
the  seat  of  brawny  infiltration  ;  in  the  intestinal  mucous  membrane, 
and  sometimes  in  the  skin,  carbunculous  infiltrations  may  occur.  As 
in  all  infectious  diseases,  the  course  varies  in  rapidity  according  to 
the  amount  and  intensity  of  the  poison  absorbed  and  the  resisting 
powers  of  the  patient ;  it  may  be  foudroyante  (apoplectiform),  or 
may  go  on  for  several  days.  The  herbivora  are  more  readily  infected 
than  omnivora  or  carnivora.     The  contagion  adheres  to  the  products 


TRAUMATIC  AND  IXFLAMMATORY  DISEASES,   ETC.  435 

of  the  disease  and  the  patient.  Nothing  certain  is  known  about  the 
origin ;  since  it  is  more  frequent  in  some  regions  than  others,  it  has 
been  thought  that  the  soil  and  food  had  some  eifect.  The  intestinal 
secretions  are  mixed  with  the  dung  of  the  animals,  and  their  poison- 
ous effects  have  been  proved.  If  such  dung  be  spread  over  the  land, 
and,  either  fresh  or  dried  on  hay,  be  eaten  by  other  animals,  they 
may  be  attacked  by  the  disease. 

Transfer  of  the  affection  to  man  is  most  often  through  the  matter 
of  the  pustule ;  if  this  or  the  dried  skin  of  the  dead  animal  be  brought 
in  contact  with  the  skin  of  man,  even  if  it  is  uninjured,  the  poison 
may  enter  through  a  hair-follicle  or  sweat-gland ;  the  result  is  a  pus- 
tule, at  first  unnoticed,  then  itching  and  burning,  fa  the  centre  of 
which  a  black  blood-blister  soon  forms  ;  high  fever  soon  comes  on. 
In  bad  cases  the  cutaneous  inflammation  early  assumes  the  character 
of  carbuncle,  terminating  quickly  in  gangrene,  and  if  left  to  itself  the 
disease  is  usually  fatal. 

Internally  we  give  the  ordinary  antiseptics  ;  the  anthrax  itself  is 
to  be  energetically  attacked  by  incision,  excision,  caustic  potash, 
nitric  acid,  etc.  If  the  patient  comes  under  treatment  early  and 
there  is  no  intense  blood-poisoning,  there  is  hope  of  cure ;  if  the  pus- 
tule is  fully  developed  and  septic  symptoms  have  begun,  death  is 
certain.  Recent  observations  show  that  infection  in  veterinary  sur- 
geons from  post-mortem  examinations  of  diseased  animals  does  not 
have  such  a  dangerous  course,  but  often  gives  rise  to  a  phlegmon  of 
medium  intensity,  which  may  pass  off  in  a  few  days  with  scaling  off 
of  the  skin.  Quite  lately  Leuhe  and  W.  MiXller  have  described  cases 
where  severe  intestinal  inflammation  ending  fatally  followed  the  use 
of  flesh  from  animals  that  had  died  of  carbuncle.  According  to  Sol- 
linger^  the  milk  of  cows  with  this  disease  proves  infectious  to  man. 
It  is  still  a  disputed  question  whether  malignant  pustule  may  also 
develop  primarily  in  man ;  whether  the  malignant  carbuncle  de- 
scribed in  Lecture  XXI.  always  comes  from  infection,  or  may  come 
spontaneously  from  the  same  causes  as  in  animals.  Eminent  sur- 
geons and  veterinarians  have  investigated  this  subject ;  inoculations 
of  secretion  from  malignant  carbuncles  of  man  on  animals  have  proved 
very  uncertain  ;  observations  have  been  contradictory  ;  in  short,  the 
relation  of  these  different  forms  of  carbuncle  and  pustules  to  each 
other,  in  regard  to  their  etiology,  has  not  yet  been  cleared  up. 

Of  late  the  view  that  the  septic  poison  of  carbuncle  is  associated 
with  certain  small  organisms  is  gaining  ground.  Davaine  especially 
holds  that  the  bacteria  (first  described  by  Pollender  in  1855)  quite 
constantly  found  in  the  blood  of  living  animals  with  carbuncle,  or  of 
those  that  have  died  of  this  disease,  are  the  cause  of  the  affection. 


436  CARBUNCLE. 

But  we  may  doubt  if  it  cannot  exist  without  bacteria,  as  it  is  asserted 
that  with  blood  from  carbunculous  animals,  Avhich  contains  no  bac- 
teria, other  animals  may  be  infected.  In  Leuhe's  cases,  already  men- 
tioned, countless  cocci  and  bacteria  were  found  in  the  intestinal  mu- 
cous membrane  (mykosis  intestinalis,  Buhl).  Many  assert  that  the 
bacteria  found  in  carbuncle  diflfar  from  those  resulting  from  decompo- 
sition. JBoUinger  asserts  that  small  cocci  (bacteria  germs)  exist  in 
the  blood  of  every  animal  affected  with  carbuncle,  but  that  from 
their  small  size  they  often  escape  observation  ;  he  considers  their 
vegetation  as  the  essential  cause  of  the  disease,  which  is,  however, 
favored  by  the  species  of  the  animal,  its  nourishment,  and  the  char- 
acter of  the  soil  and  stabling.  My  own  observations  have  shown 
me  that  the  bacteria  of  carbuncle,  like  those  in  the  blood  and  peri- 
cardium of  decomposing  bodies,  belong  to  the  meso-  and  megalo-bac- 
teria  ;  and  also  that  cocci  and  even  permanent  germs  (Dauersporen) 
often  form  in  them.  On  inoculating  blood  containing  bacteria  in  the 
cornea  of  rabbits,  Frisch  saw  stellate  figures  form,  evidently  com- 
posed of  bacteria,  which  developed  enormously  and  led  to  suppura- 
tion of  the  eyeball,  but  never  to  general  infection  or  the  death  of  the 
animal.  The  inoculations  of  blood  from  horses  and  cattle  which  had 
shortly  before  died  of  carbuncle  on  rabbits.  Guinea-pigs,  sheep,  and 
dogs,  in  the  cases  I  witnessed,  proved  more  certain  in  proportion  to 
the  certaint}'  of  the  presence  of  bacteria ;  and  uncertain  results  oc- 
curred, as  they  did  in  the  cases  of  other  observers. 

We  must  also  mention  the  mouth  and  hoof  disease  of  cattle, 
as  recent  observations  have  proved  its  transfer  to  man.  In  cattle 
the  disease  consists  in  the  formation  of  vesicles  and  pustules  on  the 
mucous  membrane  of  the  raouth,  at  the  roots  of  the  hoof,  and  on  the 
udders  of  cows  ;  these  heal  spontaneously  in  from  five  to  fourteen 
days  ;  and  although  the  animals  often  emaciate  greatly,  only  the 
young  ones  ever  die.  The  disease  seems  to  spread  epidemically 
through  the  secretion  from  the  pustules,  the  milk,  and  perhaps  also 
through  an  evanescent  contagion.  The  transfer  of  the  affection  to 
man  results  from  contact  of  abrasions  of  the  skin  with  the  matter 
from  the  pustules,  or  from  free  use  of  uncool^ed  milk  of  the  diseased 
animals.  If  the  latter  has  been  the  mode  of  origin,  vesicles  and  pus- 
tules form  in  the  mouth  and  on  the  hands  and  feet,  as  in  the  cattle. 
Catarrh  of  the  throat  and  stomach  may  be  added.  The  treatment 
consists  in  frequently  rinsing  the  mouth,  painting  the  vesicles  with 
solution  of  borax  (five  parts  to  thirty  of  honey),  and  touching  the 
pustules  on  hands  and  feet  with  nitrate  of  silver.  Cooking  destroys 
the  infecting  matter  in  the  milk.  It  is  not  improbable  that  some 
aphthous  diseases  of  small  children  arise  from  infection  by  milk  thus 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,   ETC.  437 

diseased.  In  man  the  disease  runs  its  course  without  much  danger, 
as  it  does  in  cattle ;  only  very  young,  feeble  children  could  be  endan- 
gered by  it. 

[According  to  Letheby  ("  Lectures  on  Food  "),  "  Dr.  Livingstone 
tells  us  that  when  the  flesh  of  animals  affected  with  pleuro-pneumonia 
is  eaten  in  South  Africa  by  either  natives  or  Europeans,  it  invariably 
produces  malignant  carbuncle.  He  says,  indeed,  that  the  effects  of 
this  poison  were  often  experienced  by  the  missionaries  who  had  eaten 
the  meat,  even  when  the  presence  of  the  disease  was  scarcely  per- 
ceptible. .  .  .  The  virus,  he  says,  is  neither  destroyed  by  boiling 
nor  by  roasting,  and  of  this  fact  he  had.  innumerable  instances. 
Now  it  is  a  remarkable  cireumstance  that  ever  since  the  importation 
of  this  disease  (pleuro-pneumonia)  into  England  from  Holland  in 
1842,  the  annual  number  of  deaths  from  carbuncle,  phlegmon,  and 
boils  has  been  gradually  increasing."] 

Canine  madness  (hydrophobia,  lyssa),  which  is  transferred  from 
animals  to  men,  is  better  known  and  more  frequent  than  either  of  the 
above  diseases.  From  unknown  reasons,  the  disease  appears  to  de- 
velop primarily  only  in  dogs;  but  from  the  bite  of  this  animal,  and  the 
entrance  of  its  saliva  into  the  wound,  it  may  be  transferred  to  any 
animal,  and  ai:)parently  the  poison  does  not  decrease  by  inoculation, 
but  is  always  propagated  with  equal  power.  For  instance,  a  mad  dog 
bites  a  cat ;  the  disease  develops  in  the  latter,  and  she  bites  a  man ; 
an  animal  being  inoculated  with  the  saliva  or  blood  of  the  man  will 
have  the  disease. 

The  symptoms  in  the  dog  are  described  by  the  veterinarians  as 
follows:  We  distinguish  a  raving  and  a  quiet  madness;  previous  to 
both  of  them  the  dog  is  downcast  and  eats  little.  After  this  state 
has  lasted  about  a  week  the  raving  madness  begins;  the  dog  runs 
about  in  an  objectless,  unsteady  way,  apparently  urged  by  some  in- 
ward anxiety  ;  if  irritated,  he  bites  at  any  thing  coming  in  his  way  ; 
the  mouth  is  dry ;  he  tries  to  drink,  but  soon  runs  from  the  water  without 
taking  it ;  he  emaciates,  he  totters,  then  his  hind-legs  become  par- 
alj'zed,  his  barking  changes  to  a  kind  of  howl,  twitchings  come  on, 
and  in  three  or  four  days  are  followed  by  death.  In  the  still  mad- 
ness, paralysis  of  the  muscles  of  the  lower  jaw  occurs  early,  render- 
ing biting  and  eating  impossible.  The  other  symptoms  are  the  same 
as  just  described.  Some  do  not  consider  these  two  forms  of  the 
disease  as  distinct,  but  as  different  stages,  only  lasting  a  longer  or 
shorter  time.  On  autopsy  of  animals  dying  from  this  disease,  we 
usually  find  the  gastric  and  intestinal  mucous  membrane  much  red- 
dened ;  this  is  probably  merely  due  to  the  various  foreign  bodies 
that  the  dog  has  swallowed.     Beyond  this,  we  find  nothing  abnor- 


438 


HYDROPHOBIA. 


mal,  especially  in  the  brain  and  spinal  medulla ;  but  we  must  add  that 
hitherto  no  microscopical  examinations  of  these  parts  have  been 
made,  while  it  is  very  probable  that,  in  cases  where  paralysis  very 
evidently  occurs,  there  is  degeneration  of  the  spinal  medulla,  although 
otherwise  the  predominant  character  of  the  disease  is  humoral. 

As  regards  the  transfer  of  hydi'ophobic  poison  to  man,  it  is  a  relief 
to  know  that  all  those  bitten  do  not  become  sick,  but  that  only  about 
one  out  of  twenty  cases  bitten  is  attacked.  Usually  the  bite  heals 
readily ;  more  rarely  it  suppurates  a  long  time,  which  is  to  be  regarded 
as  very  favorable ;  the  local  reaction  is  never  of  such  a  nature  as  to 
threaten  danger,  and  in  this  respect  the  hydrophobic  poison  differs 
essentially  from  the  animal  poisons  heretofore  mentioned ;  it  is  not  a 
phlogogenous  poison.  The  outbreak  of  the  disease  rarely  occurs  in 
less  than  six  weeks  after  the  bite,  frequently  even  later  ;  a  case  lias 
recently  been  observed  where  the  disease  first  appeared  after  six 
months.  Older  writers  give  a  still  longer  period  of  incubation ;  there 
is  a  popular  belief  that  the  figure  9  plays  an  important  role ;  it  is 
said  that  the  disease  appears  the  9th  day,  the  9th  week,  or  the  9th 
month  after  the  bite,  and  that  before  the  end  of  the  9th  year  there  is 
no  security  that  the  disease  will  not  appear.  This  is  certainly  a  fable, 
which  is  readily  explained  by  the  fact  that  the  long  duration  of  the 
incubation  is  very  strange,  and  has  given  rise  to  the  various  stories. 
Where  the  poison  remains  hidden  during  this  long  time,  whether  in 
the  cicatrix,  in  the  next  lymphatic  glands,  or  in  the  blood,  is  entirely 
unknown.  In  a  few  cases  only  it  has  been  observed  that,  shortly 
before  the  outbreak  of  the  disease,  the  patient  had  noticed  a  slight 
redness  of  the  cicatrix ;  then  the  first  symptoms  were  great  irritability, 
excitement,  and  restlessness,  and  in  rare  cases,  even  in  this  stage, 
there  were  spasms  on  attempting  to  swallow.  The  irritability  con- 
stantly increases;  the  light,  every  noise  or  drauglit,  pains  these  un- 
fortunate patients,  and  may  excite  general  spasms  and  the  pains  on 
swallowing.  Now,  very  gradually,  the  fear  of  water  appears ;  the 
patients  suflFer  from  unspeakable  thirst,  and  as  soon  as  they  see  any 
liquid  they  are  attacked  by  horrible  anxiety  and  spasms  ;  occasionally, 
attacks  of  deep  spasmodic  inspiration  follow;  the  patient  cannot  sleep, 
and  is  in  constant  dread  of  the  least  sound,  as  any  thing  excites  the 
convulsions,  which  finally  affect  the  whole  body,  and  then  lead  to 
actual  madness,  with  the  appearance  of  most  fearful  anxiety.  But, 
on  the  whole,  the  patients  may  be  readily  calmed  b}'  quiet  and  by 
speaking  to  them,  and  become  either  perfectly  resigned  or  melancholy. 
Occasionally  they  warn  those  about  them  not  to  come  too  near  or  they 
may  bite  them,  but  they  are  not  at  all  malignant,  as  they  were  for- 
merly described.     Great  salivation  and  foaming  from  the  mouth  do 


TRAUMATIC   AND   INFLAMMATORY  DISEASES,   ETC.  439 

not  begin  till  toward  the  end  ;  in  some  cases  death  is  preceded  by  the 
severest  tetanic  spasms;  others  die  after  the  convulsions  and  the  fear 
of  water  have  completely  ceased,  and  when  the  patient  and  surgeon 
have  been  led  into  vain  hopes.  Unfortunately,  pathological  anatomy 
gives  us  no  explanation  of  this  wonderful  and  fearful  disease.  There 
can  be  no  doubt  that  the  spinal  medulla  is  affected,  but  it  has  not  yet 
been  determined  whether  the  nerve-substance  itself  is  diseased. 

As  regards  the  prognosis,  in  those  patients  where  the  disease  has 
broken  out,  there  is  no  hope.  It  may  be  considered  proper,  in  all 
cases,  to  cauterize  or  burn  out  the  bites  of  mad  animals,  and  to  keep 
them  suppurating  a  long  time;  at  least  this  is  the  only  rational  treat- 
ment. It  cannot  be  certainly  decided  from  past  observations  whether 
excision  of  such  a  cicatrix  can  be  useful  after  the  disease  has  already 
broken  out  ;  it  would  at  all  events  be  a  rational  treatment.  In  the 
developed  disease,  almost  all  the  powerful  remedies  in  the  materia 
medica  and  in  surgery  have  been  tried  ;  all  the  narcotics  have  been 
used  in  large  and  small  doses  ;  opium  and  belladonna  especially, 
used  in  almost  poisonous  doses,  and  the  artificial  benumbing  of  the 
patient,  have  at  least  alleviated  their  sufferings,  if  they  have  done 
no  other  good.  The  limb  containing  the  cicatrix  has  been  amputated 
in  vain.  In  one  patient,  Dieffenbach  tried  transfusion  in  vain. 
Where  there  is  dread  of  water,  some  fluid  may  be  introduced  through 
a  tube  ;  the  patients  are  most  comfortable  when  at  absolute  rest  in 
a  half -darkened  room  ;  in  combating  the  convulsions,  chloroform 
narcosis  has  repeatedly  proved  most  serviceable,  and  patients  who 
have  once  become  acquainted  with  this  remedy  beg  for  it  again. 
But  this  comprises  the  little  that  we  can  do  for  these  unfortunates. 

[Lately  Weller  claims  that  an  anatomical  characteristic  of  Lyssa 
in  dogs,  as  in  men,  is  a  marked  hyperseraia  in  the  medulla  oblongata 
and  upper  part  of  the  cervical  medulla  with  marked  fulness  of  the 
perivascular  spaces  of  lymphoid  cells  ;  this  process  differs  from 
acute  myelitis  by  not  going  on  to  softening. 

The  only  treatment  that  offers  any  hope  in  the  developed  dis- 
ease is  by  subcutaneous  injections  of  curare.  Ctirare  paralyzes 
voluntary  muscles,  and,  when  given  subcutaneously,  repeated  till 
relaxation  results,  may  cure  some  cases  ;  but  its  efficacy  depends 
much  on  the  special  sample  used.  Of  late,  some  cases  have  been 
arrested  by  stretching  the  chief  nerve-trunk  or  some  of  its  branches, 
in  the  limb  primarily  affected.  We  do  not  know  what  changes 
may  be  induced  in  the  nerve,  nor  is  it  always  successful,  even 
when  we  know  the  point  of  origin  of  the  tetanus.  The  fact  of 
nerve-stretching  having  proved  useful  in  some  cases  would  tend 
to  show  that  tetanus  is  due  to  some  affection  of  the  peripheral 


440  SXAKE-BITES,  ETC. 

nerves.  The  number  of  deaths  yearly  from  hydrophobia  is,  in 
Prussia,  71  ;  Austria,  58  ;  France,  24  ;  Bavaria,  17  ;  vi^hile  in  Con- 
stantinople, where  there  are  so  many  dogs,  it  is  said  the  disease 
does  not  occur. 

Sometimes  a  single  sting  from  an  insect  will  cause  severe  symp- 
toms of  general  poisoning,  without  our  being  able  to  suggest  any 
other  cause  for  such  unusual  reaction  than  individual  predisposition, 
or,  possibly,  a  direct  entrance  of  the  poison  into  a  large  lymphatic 
vessel.  The  patient  quickly  becomes  comatose,  the  skin  cool  and 
covered  with  clammy  sweat,  the  face  cyanotic,  breathing  superficial 
and  slow,  the  pulse  rapid  and  scarcely  perceptible.  These  symp- 
toms usually  subside  in  a  few  hours,  along  with  the  local  symp- 
toms ;  but  for  some  days  the  patients  continue  to  feel  heavy. 

In  Southern  Germany,  bee-tenders  treat  stings  with  scorpion- oil 
(olive-oil  containing  scorpions)  ;  sensible  and  trustworthy  observers 
say  this  oil  is  a  very  decided  antidote  ;  swelling  and  pain  subside 
soon  after  its  application.  If  this  oil  is  not  to  be  had,  we  may  ap- 
ply ammonia  over  the  injured  i^art,  but  this  is  only  useful  immedi- 
ately after  the  sting. 

All  observations  made  with  snake-poison  show  that  its  quality 
is  always  the  same.  The  bites  of  poisonous  serpents  always  cause 
the  same  series  of  symptoms,  although  the  intensity  of  the  action 
may  vary  with  the  variety  of  the  serpent,  and  even  with  the  same 
animal,  according  to  the  season  of  the  year,  and  to  the  length  of 
time  that  has  elapsed  since  it  last  bit  anything.  If  the  bites  fol- 
low each  other  quickly,  the  secretion  from  the  poison-glands  is  ex- 
hausted, so  that  the  later  bites  are  less  active  than  the  first. 

Even  when  dried  the  poison  retains  its  activity,  nor  is  it  de- 
stroyed by  alcohol  ;  for  persons  have  been  poisoned,  even  fatally, 
by  injuring  themselves  Avith  the  fangs  of  serpents  preserved  in 
alcohol. 

In  the  English  provinces  of  the  East  Indies,  as  many  as  twenty 
thousand  persons  are  said  to  die  annually  from  snake-bites. 

Poison  in  the  secretion  of  certain  inflamed  parts,  as  puerperal 
endometritis,  septic  peritonitis,  etc.,  may  be  very  virulent.  Infec- 
tion from  this  source  depends  on  the  facility  with  which  it  passes 
through  the  skin  ;  small  tears  which  do  not  bleed,  and  excoriations, 
are  more  susceptible  to  infection  than  deep  incised  wounds  ;  this  is 
because  in  the  latter  case  the  flowing  blood  washes  the  putrid  poi- 
son from  the  wound. 

Dangerous  infections  with  cadaveric  poisons  usually  follow  in- 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,  ETC.  441 

juries  so  slight  that  they  cannot  afterward  be  found,  and  nothing 
is  noticed  till,  a  few  hours  after  the  infection,  at  the  point  of  injury, 
there  may  be  discoloration  and  swelling.  In  such  cases  there  is 
only  one  remedy  for  combating  the  severe  general  symptoms,  as 
for  opposino-  the  primary  gangrene  induced  by  contact  with  the 
cadaveric  poison  :  this  is  a  long,  deep  incision,  dividing  the  dis- 
colored skin  throughout  its  length,  and  so  that  its  edges  may  gape  ; 
a  cross-cut  may  also  be  required.  Bleeding  should  be  encouraged, 
and  the  wound  may  be  sucked.  Local  cauterizations  are  not  indi- 
cated—they cannot  affect  the  virus  already  diffused  in  the  tissue  ; 
but  you  may  pack  the  wound  with  charpie  soaked  in  B  11x010' s  fluid 
and  envelop  the  limb  in  compresses  wet  in  hot  water,  changing  this 
every  three  hours.  At  the  same  time  the  limb  should  be  kept  im- 
movable and  elevated,  and  quiet  secured  by  morphine. 

Carbuncle-poison  has  been  very  carefully  studied,  and  it  is 
found  to  accompany  a  long,  rod-like  fungus,  the  bacillus  anthracis  ; 
this  is  found  in  the  blood  and  tissues  of  the  carbunculous  animal, 
especially  in  the  vessels  of  the  intestinal  follicles  and  kidneys  ;  it 
may  be  bred  in  suitable  fluid,  and  this  being  introduced  into  the 
blood  of  healthy  animals  will  cause  carbuncle.  Its  resisting  power 
is  great  ;  when  dried  the  contagion  probably  lasts  indefinitely  ; 
heating  to  220°  kills  it,  but  it  resists  the  cold  induced  by  liquefying 
carbonic  acid.  The  oi-ganized  contagion  clings  to  the  products 
of  the  disease,  and  everything  that  has  come  in  contact  with  the 
diseased  animal  may  carry  the  germs.  According  to  Pasteur,  in- 
fection probably  never  occurs  through  the  uninjured  skin  or  the 
lungs,  but  chiefly  through  injuries  of  the  mucous  membrane  of  the 
digestive  tract.  In  the  parts  of  France  where  carbuncle  is  epi- 
demic, the  contagion  fix)m  dying  and  slaughtered  animals  is  passed 
to  the  vegetation  and  soil  before  the  cadaver  putrefies  ;  putrefac- 
tion destroys  the  bacilli.  Animals  become  infected  from  their  food 
containing  bacilli  coming  in  contact  with  superficial  injuries  of  the 
mucous  membrane  of  the  mouth  and  pharynx,  which  are  very  com- 
mon, and  may  be  demonstrated.  The  bacilli  also  occur  in  the  soil ; 
worms  carry  them  about  and  bring  them  to  the  surface. 

Inoculation  of  animals  gives  them  a  certain  immunity  to  splenic 
fever.  Collin  has  shown  that  the  disease  remains  local  till  the  poi- 
son enters  the  lymphatic  glands,  then  it  becomes  general ;  Toks- 
saint  found  that  this  generalization  did  not  occur  if  inflammation 
was  set  up  in  the  lymphatic  glands  by  defibrinated  blood  of  car- 
bunculous animals  from  which  the  bacilli  had  been  removed.  If 
animals  thus  treated  be  inoculated  with  fresh  poison,  it  will  be  re- 


442  CARBUNCLE. 

tained  by  the  glands,  and  the  animal  remains  healthy.  If  pregnant 
sheep  be  inoculated  in  the  last  months  of  pregnancy,  their  lambs 
are  secure  against  carbuncle.  It  seems  as  if  all  the  physiological 
and  pathological  products  might  contain  the  poison  ;  even  the  milk 
is  infectious  {Bollinger).  All  animals  are  not  equally  predisposed  ; 
some  have  entire  immunity,  in  others  the  disease  remains  local. 
The  food,  state  of  the  soil,  stabling,  etc.,  have  much  to  do  with  the 
epidemic  occurrence  of  the  disease.  According  to  Davaine,  the  de- 
velopment of  carbuncle  bacteria  is  most  certainly  arrested  by  tinc- 
ture of  iodine. 

Many  different  plans  of  treatment  have  been  tried  ;  besides  in- 
ternal remedies,  such  as  quinine,  carbolic  acid,  iodine,  etc.,  attempts 
have  always  been  made  to  destroy  the  poison  that  has  entered  the 
body.  Formerly,  the  infected  point  was  removed  by  a  crucial  in- 
cision if  possible,  or  several  deep  cuts  were  made,  and  the  actual 
cautery,  caustic  potash,  fuming  nitric  acid,  chloride  of  zinc,  etc., 
applied.  The  burning  induced  energetic  reaction  in  the  tissues, 
thus  limiting  the  gangrene.  Then  subcutaneous  injections  of  car- 
bolic acid  were  tried,  but  they  did  not  prove  so  successful  as  was 
hoped.  Now  many  surgeons  (Hoser  and  others)  recommend  ex- 
pectant treatment,  moist  warmth,  lead-Mater,  chloride  of  lime,  etc., 
in  cases  where  the  extent  of  the  local  trouble  indicates  that  neither 
excision  nor  cauterization  would  get  rid  of  all  the  infiltrated  tissue. 
Experience  has  shown  that  even  extensive  carbuncle  with  great 
loss  of  substance  may  heal  spontaneously  ;  hence,  it  is  well  at  the 
onset  of  the  disease  to  incise  and  cauterize  the  diseased  part,  but, 
when  the  local  redness  and  cedema  are  extensive,  avoid  excision  and 
burning,  and  try  expectant  treatment  and  carbolic  injections.  The 
results  of  local  treatment  are  best  when  the  virus  has  not  entered 
the  lymphatic  glands  ;  when  the  disease  has  become  general,  treat- 
ment is  of  little  use,  and  the  result  depends  on  the  resisting  power 
of  the  patient.  Zenbe  and  W.  3Iull€r  have  quite  recently  reported 
cases  of  fatal  inflammation  of  the  intestines  after  eating  flesh  of 
animals  dying  of  carbuncle.  In  these  cases  the  intestinal  mucous 
membrane,  especially  the  capillaries  of  the  intestinal  follicles,  were 
found  full  of  bacilli  and  cocci  (mycosis  intestinalis,  JBiihl).  But 
the  Gypsies  in  Hungary  eat  such  flesh  without  fear  or  injury,  while 
those  who  had  butchered  the  animals  had  malignant  pustules. 
Possibly  the  flesh  was  not  eaten  till  it  began  to  decompose,  and  the 
bacilli  were  killed  by  this  act. 

The  attention  of  physicians  and  sanitarians  has  lately  been  di- 
rected to  a  malady  called  rag-disease  occurring  among  operatives 


TRAUMATIC   AND   INFLAMMATORY   DISEASES,  ETC.  443 

in  paper-factories,  partieulai-ly  in  those  employed  in  sorting  and 
picking,  and  thus  exposed  to  dust  from  the  rags.  It  seems  proved 
that  this  disease  is  caused  by  carbuncle  contagiura,  the  rags  having 
been  exposed  to  this  poison  in  the  blood  or  secretions  of  the  ani- 
mal ;  and  when  dried  and  disturbed  the  dust  floats  off  to  poison 
the  workmen  by  getting  into  any  sores  or  entering  their  lungs. 

It  is  not  yet  certain  whether  splenic  fever  in  man  is  always  due 
to  infection,  or  may  arise  spontaneously  under  certain  conditions.] 


The  three  diseases  last  mentioned  enter  so  much  into  the  domain 
of  veterinary  surgery,  sanitary  regulations,  and  internal  medicine, 
thit  I  could  here  give  you  only  a  slight  sketch  of  them.  You  will 
lind  more  accurate  information  on  the  subject  in  Virchow''s  special 
pathology,  Bd.  II.,  Section  Zoonosen,  where  the  special  literature  is 
also  given.  In  the  surgery  published  by  V.  Pitha  and  myself  you 
will  also  find  (vol.  i.,  part  ii.)  an  exhaustive  section  on  the  Zoo- 
noses. 


CHAPTER  XIV. 

CBRONIG  INFLAMMATION,  ESPECIALLY  OF  THE 
SOFT  FARTS. 


LECTURE    XXVIII. 

Anatomy:  1.  Thickening,  Hypertrophy;  2.  Hypersecretion;  3.  Suppuration,  Cold 
Abscesses,  Congestive  Abscesses,  Fistulfe,  Ulceration. — Results  of  Chronic  Inflam- 
mation.— General  Symptomatology. — Course. 

Gentlemex  :  Having  thus  far  attended  almost  exclusively  to  acute 
afifections,  we  now  come  to  the  chronic,  and  first  of  all  to  chronic  in- 
flammation. 

In  chronic  inflammation  also,  as  in  acute,  there  are  chemical  and 
morphological  changes  and  nutritive  disturbances  of  tissue  ;  they  are 
followed  by  softening  and  solution,  or  molecular  disintegration,  or 
extensive  slowly-developing  necrosis  of  tissue.  To  these  processes 
are  added  dilatation  of  the  vessels,  exudation,  and  formation  of  new 
tissue.  This  combination  may  vary ;  chronic  inflammation  leads  to  very 
complicated  appearances,  according  as  one  or  other  stage  of  the  pro- 
cess remains  more  or  less  permanent,  and  according  as  there  is  dis- 
integration, softening,  or  hardening  of  the  tissue  implicated,  and  as  to 
the  varied  fate  of  the  inflammatory  neoplasia.  Etiologically,  the  con- 
ditions in  chronic  inflammation  are  much  more  complicated  ;  for  there 
it  is  not  merely  a  question  about  an  irritation  only  once,  as  an  injury 
or  a  burn,  and  their  sequences,  but  we  have,  1,  to  explain  the  cause 
of  the  inflammation ;  and,  2,  why  it  assumes  a  chronic  character.  1 
shall  first  explain  to  you  what  anatomical  changes  take  place  in  the 
tissues  during  chronic  inflammation,  in  doing  which,  just  as  we  did  in 
'acute  inflammation,  we  shall  here  take  the  connective-tissue  as  the 
ordinary  seat  of  the  disease.  Besides  the  distention  and  multiplication 
of  the  capillary  vessels  by  formation  of  loops  in  acute  inflammation, 
we  found  serous  and  plastic  infiltration  of  the  tissue  to  be  the  essen 
tial   anatomical  appearances.     In  chronic  inflammation,  distention  of 


CHRONIC  INFLAMMATION   OF   THE  SOFT   PARTS.  445 

the  capillary  vessels,  or  fluxion,  is  a  less  prominent  symptom,  while 
the  new  formation  of  tissue  and  serous  infiltration  seem  to  play  a 
more  important  role.  The  cell-infiltration  of  the  tissue  takes  place  in 
few  cases,  as  it  does  in  acute  inflammation ;  but  the  individual  cells 
often  attain  a  rather  more  complete  development.  In  this  process  of 
development  the  intercellular  tissue  changes ;  the  connective-tissue 
filaments  lose  their  tough  filamentary  consistency,  the  distensibility 
and  elasticity  of  the  subcutaneous  tissue  are  impaired,  and  the  conse- 
quence, as  regards  the  coarser,  palpable,  and  visible  consequences,  is 
that  the  tissue  becomes  more  swollen  and  fatty,  and  less  movable 
than  normal.  This  is  the  first  stage  of  every  chronic  inflammation. 
The  course  may  vary  as  follows : 

1.  The  tissue  remains  permanently  in  this  state  of  serous,  and,  to 
some  extent,  plastic  firm  infiltration  ;  skin  and  subcutaneous  cellular 
tissue,  articular  capsule,  tendons,  ligaments,  fascise — in  short,  all  these 
connective-tissue  constituents  of  the  body  which  are  in  the  above 
state — on  section  present  a  rather  homogeneous,  fatty  appearance. 
In  diseases  of  the  joints  and  their  vicinity  we  see  this  most  frequently, 
and,  as  this  swelling  of  the  joint  goes  on  without  any  reddening  of  the 
skin,  it  was  formerly  called  tumor  alhus,  a  name  which  tells  nothing 
of  the  nature  of  the  process,  but  which,  hmited  to  certain  forms  of 
joint-disease,  is  practically  serviceable.  You  may  readily  imagine  that 
tissue  which  has  been  little  altered  may  return  from  this  stage  of  the 
disease  to  its  normal  state.  The  infiltrated  serum  is  reabsorbed ;  the 
cells,  which  have  newly  entered  the  tissue  or  have  newly  formed  there, 
partly  become  connective-tissue  corpuscles,  and  are  partly  destroyed  ; 
the  connective  tissue  itself  returns  to  its  former  condition,  and,  if  the 
state  of  afi'airs  be  not  exactly  as  it  was,  it  is  nearly  so ;  occasionally 
a  state  of  cicatricial  thickening  remains ;  during  the  development  of 
the  chronic  inflammation  there  may  also  have  been  small  extravasa- 
tions or  escapes  of  red  blood-cells  through  the  walls  of  the  vessels, 
from  the  increased  pressure  (according  to  Cohnheim) ;  these  change 
to  a  brownish-red  pigment,  which,  when  present  in  quantities,  gives  a 
yellowish  or  grayish  color  to  the  tissue  that  has  been  diseased.  As  a 
result  of  the  continued  excess  of  nutrient  material,  which  sometimes 
flows  to  the  diseased  part  in  chronic  inflammation,  the  tissue-elements 
may  become  larger  and  thicker ;  the  whole  tissue  may  increase ;  it 
passes  into  a  state  of  simple  hypertrophy.  But  sometimes  the  plastic 
(cellular)  infiltration  in  chronic  inflammation  may  attain  a  particularly 
high  grade  ;  from  the  infiltrated  young  cells  new  connective  tissue 
forms  in  the  old,  so  that  the  skin  may  be  thickened  to  three  or  four 
times  the  normal  extent ;  this  deposit  of  new  tissue  of  similar  forma- 
tion, in  the  old,  is  called  hyperplasia  by  the  pathological  anatomists 


446  COURSE   OF  CHRONIC  INFLAMMATION. 

When  the  thickening  of  the  skin  assumes  a  nodular  form,  it  is  usually 
termed  elephantiasis  m  the  most  general  sense  of  the  term.  Such 
hypertrophies  and  hyperplasias  of  the  connective  tissue,  which  may 
■  form  in  the  course  of  a  chronic  inflammation,  hardly  ever  recede  en- 
tirely, but  often  remam  in  the  same  state,  even  when  their  causes 
have  been  removed. 

2.  If  you  imagine  the  chronic  inflammation,  so  far  as  you  at 
present  know  it,  transferred  to  a  mucous  or  serous  membrane,  you 
will  acknowledge  that  the  secretion  cannot  remain  normal  during  the 
pathological  changes  which  afifect  the  tissue  of  these  membranes. 
Usually  it  increases,  there  is  hypersecretion  ;  chronic  inflammation  of 
a  synovial  or  mucous  membrane  may  evince  itself  chiefly  by  this 
hypersecretion. 

Chronic  catarrh  of  the  mucous  membranes  may  affect  chiefly  the 
epithelial  or  the  connective-tissue  layer  or  the  glands  of  the  mem- 
brane ;  in  many  cases  all  three  sufi"er  to  an  equal  extent.  The  same  is 
the  case  in  the  synovial  membrane  of  the  joints  ;  some  forms  of  chronic 
articular  inflammation  are  chiefly  noticeable  from  a  very  free  secretion 
of  a  watery  synovia ;  in  others,  there  is  more  thickening  of  the  syno- 
vial membrane,  and  but  little  increase  of  secretion. 

3.  Chronic  inflammation  may  also  be  accompanied  by  suppuration, 
and  its  finer  changes  are  just  as  in  the  acute  disease,  except  that 
every  thing  is  slower.  For  instance,  suppose  there  is  at  some  part  of 
the  body  a  collection  of  wandering  cells  with  a  formation  of  fluid 
intercellular  substance;  at  the  same  time,  of  course,  the  tissue  in 
which  these  cells  are  infiltrated  dies,  as  always  happens  in  circum- 
scribed cell-proliferations.  The  tissue  surrounding  the  spot  first  dis- 
eased is  gradually  infiltrated  with  cells ;  and  it  also  goes  on  to  form 
fluid  cellular  tissue  with  the  character  of  pus ;  the  infiltrated  tissue  is 
the  more  disposed  to  suppurate  and  break  down  when  its  vessels  are 
little  developed  and  do  not  supply  suSicient  qualitative  and  quantitative 
nutrient  material  to  maintain  the  further  development  of  the  exces- 
sive cells.  In  abscess,  a  circumscribed  cavity  containing  pus  is  thus 
formed,  its  walls  are  constantly  being  changed  to  pus,  suppurating. 
All  this  takes  place  very  gradually,  and  frequently  the  symptoms 
usually  appearing  in  inflammation  are  wanting ;  often  there  is  no  pain, 
redness,  or  elevation  of  temperature,  in  the  afi'ected  part,  and  usually 
there  is  no  fever.  Hence  this  variety  of  abscess,  which  comes  on 
chronically,  is  called  cold  abscess  ;  for  this  chronic  suppuration  we  use 
the  terra  ulceration  ("  verschwarung  ").  We  might  also  term  the  whole 
cavity  containing  pus  a  hollow  ulcer  ("  hohlgeschwur ") ;  but  in 
common  language  this  expression  is  applied  chiefly  to  small  cavities, 
while  larger,  slowly-forming  ones  are  called  cold  abscesses.     If  you 


CHRONIC  INFLAMMATION  OF  THE  SOFT  PARTS.  447 

examine  the  pus  from  such  an  abscess  microscopically,  you  will  find  it 
rich  in  fine  molecules,  but  rather  poor  in  well-developed  pus-cells. 
This  is  because  the  pus  has  long  been  enclosed  in  the  body,  and  is 
changed  by  disintegration  of  the  pus-cells  to  molecules,  and  by  chem- 
ical decomposition ;  by  the  latter  rich  excretions  of  fat,  especially  of 
cholesterine  crystals,  are  formed.  The  appearance  of  the  pus  to  the 
naked  eye  is  also  changed  by  these  metamorphoses,  for  it  is  usually 
thinner  and  clearer  than  in  the  acute  disease,  and  has  a  disagreeable 
odor  like  fatty  acids,  and  may  contain  fibrinous  flocculi  and  shreds  of 
necrosed  tissue.  Sometimes  it  is  months  or  years  before  the  suppu- 
ration of  the  walls  of  a  cold  abscess  has  gone  so  far  as  to  cause  per- 
foration of  the  skin.  In  some  cases  it  even  happened  that  such  an 
abscess  has  existed  for  years,  that  the  ulceration  of  its  walls  finally  stops, 
and  the  latter  are  transformed  to  a  cicatricial  capsule,  and  the  pus  is 
thus  completely  encapsulated.  If  we  have  opportunity  to  examine 
such  an  abscess,  we  find  in  it  an  emulsion-like  fluid,  occasionally  con- 
taing  crystalline  fat,  and  sometimes  without  a  trace  of  pus-cells,  so 
that,  from  the  appearances,  we  could  hardly  infer  that  the  sac  in 
question  had  been  an  abscess,  if  the  whole  previous  course  did  not 
show  it.  Much  more  rarely,  in  the  course  of  time,  when  the  abscess 
has  ceased  to  grow,  there  is  reabsorption  of  the  fluid,  a  cheesy  pulp 
being  left.  If  the  abscess  has  perforated  outwardly,  the  pus  is  evacu- 
ated, and,  under  otherwise  favorable  circumstances,  there  may  be 
healing,  as  we  shall  soon  describe.  But,  for  this  to  occur,  the  ulcera- 
tion on  the  inner  wall  of  the  abscess  must  cease,  which  generally  only 
occurs  when  there  is  a  sufficient  development  of  vessels  in  the  walls 
of  the  abscess ;  under  their  influence  the  inner  surface  of  the  abscess 
changes  to  a  vigorous  granulation-tissue,  and  then  it  condenses  and 
atrophies  to  cicatricial  tissue,  and  the  opposite  walls  of  the  cavity 
unite,  as  in  the  healing  of  acute  or  hot  abscesses ;  the  pus  escaping 
from  the  opened  cavity  grows  less,  and  finally  ceases  altogether. 
Some  time  subsequently  we  may  still  feel  the  subcutaneous  cicatrix 
of  the  abscess  as  a  callous  thickening ;  but,  in  the  course  of  time,  this 
also  passes  ofi^,  and  the  abscess-cicatrix  again  assumes  the  characteris- 
tics of  ordinary  connective  tissue.  I  will  now  make  you  acquainted 
with  a  technical  name  used  for  those  abscesses  which  do  not  originate 
at  the  points  where  first  seen,  but  which  have  moved  partly  from 
sinking  of  the  pus,  partly  from  the  ulceration  having  progressed 
chiefly  in  one  direction.  For  instance,  there  may  be  suppuration  along 
the  anterior  part  of  the  spinal  column,  which,  following  the  loose 
cellular  connective  tissue  behind  the  peritonaeum,  and  travelling  along 
the  sheath  of  the  psoas  muscle,  finally  appears  as  an  abscess  beneath 
Poupart's  ligament.     These  and  similar  abscesses  are  called  conge» 


448  COURSE   OF  CHRONIC  INFLAMMATION. 

live  abscesses.  Tlie  mode  of  healing  above  indicated  does  not  take 
place  with  desirable  rapiditj^,  but,  unfortunately,  the  general  and  local 
conditions  are  occasionally  of  such  a  nature  that,  after  the  evacuation 
of  the  pus,  acute  inflammation,  with  fever,  attacks  the  abscess,  and 
pyaemia  or  febrile  marasmus  comes  on,  or  else,  in  spite  of  the  evacua- 
tion of  the  pus,  the  chronic  ulceration  goes  on  slowly  but  steadily  in 
the  walls  of  the  cavity.  In  such  cases  the  openings  of  these  large, 
often  deeply-seated  cavities  continually  pour  out  a  thin,  bad  pus ;  the 
openings  of  such  abscesses,  whether  of  small  or  large  diameters,  are 
called  Jistidoe. 

You  may  also  imagine  the  above  process  of  suppuration  or  ulcera- 
tion as  transferred  to  a  surface  or  membrane  ;  then  we  should  have  a 
flat  or  02^en  ulcer,  but,  as  this  is  an  object  of  special  and  great  prac- 
tical importance,  we  must  treat  of  it  in  an  independent  chapter. 

4.  Chronic  inflammation  may  take  another  course  very  like  sup- 
puration, that  is,  caseous  degeneration  of  the  inflammatory  neoplasia. 
Imagine,  again,  a  great  collection  of  young  cells,  and  suppose,  further, 
that  in  the  centre  this  group  undergoes  molecular  disintegration,  and 
forms  a  cheesy  pulp  without  separation  of  fluid  intercellular  substance. 
Plastic  infiltration  goes  on  slowly  in  the  periphery  of  the  caseous  spot, 
by  the  collection  of  wandering  cells,  but  the  infiltrated  tissue  also 
passes  into  the  caseous  metamorphosis,  and  thus  the  central  focus 
constantly  increases.  Here,  also,  as  in  suppuration,  the  failure  of  a 
vascularization  keeping  pace  with  the  cell-formation  is  the  local  cause 
of  the  disintegration  ;  here  is  a  form  of  ulceration  that  may  be  termed 
"  caseous  ulceration  *'  (a  vascular,  dry  necrosis).  When  these  yellow 
spots  are  found  in  the  cadaver,  it  is  often  supposed  that  they  corre- 
spond to  a  dried  collection  of  pus,  but  this  is  not  true,  or,  at  least, 
very  rarely  so ;  most  of  these  cheesy  collections  were  from  the  first  in 
miniature  what  they  now  are  in  gross,  and  were  never  fluid  pus.  It 
may  very  readily  be  proved  experimentally  that  these  caseous  spots 
may  proceed  directly  from  the  inflammatory  new  formation  without 
suppuration.  If,  for  instance,  by  introducing  a  foreign  body  (as  a  se- 
ton)  into  the  subcutaneous  tissue  of  a  rabbit,  you  excite  continued 
inflammation,  in  the  course  of  a  few  days  a  yellow,  cheesy  mass  forms 
around  the  foreign  body  ;  it  is  true  this  is  the  same  for  the  rabbit  as 
pus  is  for  a  man,  but  it  was  never  fluid  pus.  There  are  also  morbid 
processes  in  man  in  which,  during  chronic  inflammation,  this  caseous 
transformation  occurs  instead  of  suppuration.  In  man,  the  further 
fate  of  these  foci  varies.  If  the  process  take  place  in  a  part  not  too 
far  below  the  surface,  it  may,  by  advancing  from  within  outward,  cause 
perforation ;  the  pulp  is  evacuated,  and  the  cavity  may  gradually 
close  as  a  cold  abscess  does.     Wlien  this  is  the  termination,  it  is  usu- 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS.  449 

ally  accompanied  by  secondary  softening  of  the  mass,  which  is  at  fii'st 
dry  and  cheesy,  and  this  fluid  pulp  under  the  microscope  is  found  to 
be  composed  almost  entirely  of  molecular  granules,  some  fat,  shreds 
of  tissue,  and  half-atrophied  cells.  The  above  process  may  be  seen 
especially  often  in  chronic  inflammation  of  the  lymphatic  glands,  but 
in  them  the  spontaneous  throwing  off  of  the  caseous  deposit  takes 
place  very  slowly,  hence  these  fistula?  of  lymphatic  glands  often  re- 
main stationary  for  months  or  years. 

Another  termination  is  for  the  caseous  deposit  to  attain  only  a 
slight  extent,  then  to  atrophy  entirely,  and  to  take  up  such  a  quantity 
of  lime-salts  as  to  finally  form  a  chalky  concrement,  which  is  concen- 
trically enclosed  by  a  cicatrix.  But,  as  was  stated,  this  only  occurs 
in  small  caseous  deposits. 

5.  There  is  still  another  form  of  chronic  inflammation,  which  is  ac- 
companied by  the  deposit  of  a  peculiar  substance,  the  so-called  larda- 
ceous  or  amjdoid,  from  the  blood.  But  I  shall  not  enter  into  this 
subject  further,  for  this  form  of  disease  occurs  chiefly  in  the  internal 
organs,  and  hence  has  only  an  indirect  interest  for  us. 

First,  as  regards  the  results  of  chronic  inflammation  in  a  purely 
histological  view,  thej'  vary.  The  cell-infiltration  and  the  neojolastic 
process  goes  on  chiefly  in  the  connective  tissue,  and  after  its  termina- 
tion the  final  result  is  either  a  restitutio  ad  integrum  or  a  cicatrix  after 
the  part  has  been  destroyed  by  ulceration.  When  this  process  attacks 
muscles  or  nerves,  the  tissues  suffer  severely  secondarily^  Tlie  con- 
tractile substance  in  the  muscle,  as  well  as  the  axis-cylinder  and 
medullary  sheath  of  the  nerve-filament,  is  not  unfrequently  destroyed  by 
molecular  disintegration  or  fatty  degeneration,  due  to  the  disturbance 
of  nutrition.  Hence  atrophy  of  the  muscles  and  paralysis  may  result 
from  chronic  inflammation.  How  far  the  regenerative  power  of  muscles 
and  nerves  goes  under  such  circumstances  is  not  decided.  Molecular 
destruction  and  fatty  degeneration  may  also  occur  without  inflamma- 
tion of  the  connective  tissue  enveloping  the  muscles  and  nerves.  But 
I  do  not  think  we  are  justified  in  tei-ming  such  a  process  of  fatty 
disintegration  of  the  protoplasm  inflammation  of  the  muscles  and 
nei-ves,  as  has  been  done  by  Virchow  in  the  muscles,  at  least,  although 
it  must  be  acknowledged  that,  in  the  great  majority  of  cases,  the  ap- 
pearance of  fat-granules  in  the  protoplasm  may  be  regarded  as  the 
first  expression  of  pathological  (but  not  always  retrogressive)  pro- 
cesses in  the  body  of  the  cell  {StrlcJcer).  The  fatty  disintegration  of 
a  tissue  may  be  the  result  of  inflammation,  or  may  even  accompany 
it ;  but  to  seek  in  it  the  nature  of  the  inflammation,  and  to  regard  the 
latter  as  a  disturber  of  nutrition  to  so  wide  an  extent,  does  not  seem 
to  render  it  more  comprehensible  or  of  practical  benefit.  We  regard 
30 


450  SYMPTOMS   OF   CHRONIC   INFLAMMATION. 

every  inflammation  as  accompanied  by  infiltration  of  the  tissue  with 
cells.  

After  these  general  anatomical  considerations,  let  us  briefly  run 
(hrough  the  symptoms  of  chronic  inflammation.  They  are  the  same 
as  in  acute  inflammation,  only  they  often  come  in  a  different  order 
and  in  other  combinations,  and  are  usually  less  intense. 

SicelUng  of  the  diseased  j^art  is  usually  the  first  noticeable  sj-mp- 
tom  ;  it  depends  partly  on  serous,  partly  on  plastic  infiltration.  The 
parts  feel  doughj^,  and  at  first  quite  firm ;  if  an  abscess  forms,  as  may 
happen  in  the  course  of  weeks  or  months,  fluctuation  gradually  be- 
comes more  evident.  We  shall  onl}'  pei'ceive  redness  of  the  inflamed 
parts,  when  they  lie  on  the  surface,  for,  as  the  vessels  are  occasionally 
but  Kttle  distended,  it  is  not  very  intense  or  extensive.  We  may 
readily  detect  chronic  inflammation  of  the  nasal  mucous  membrane,  or 
of  the  conjunctiva,  by  the  swelling,  redness,  and  increased  secretion. 
Chronically  inflamed  skin  gradually  assumes  a  bluish  or  brownish-red 
color.  But,  if  the  inflamed  parts  lie  deep,  the  skin  is  not  discolored, 
and  only  becomes  red  when  the  deep  chronic  inflammation  finally  im- 
plicates the  skin,  as  in  the  perforation  of  cold  abscesses.  Pain  is  one 
of  the  symptoms  of  chronic  inflammation  that  varies  most ;  in  some 
very  tedious  cases  it  is  entirely  absent,  but  in  other  cases  may  be  very 
severe,  having  a  tearing,  boring  character,  sometimes  appearing  spon- 
taneously, at  others  only  on  pressure,  or  on  merely  touching  the  parts. 
The  funcUonal  disturbance  depends  essentially  on  the  pain  and  on  the 
anatomical  changes  in  the  parts.  Heat,  the  temperature  appearing 
elevated  when  the  hand  is  laid  on  the  part,  is  not  usually  marked,  or 
is  very  slight. 

Fever  is  a  symptom  not  necessarily  pertaining  to  chronic  inflam- 
mation ;  it  usually  appears  only  when  the  inflammation  assumes  an 
acute  character,  as  not  unfrequently  occurs  during  its  course,  especially 
when  the  body  has  been  much  debilitated  by  long-continued  suppura- 
tion. Then  we  have  the  so-called  hectic  fever^  a  febris  continua,  or 
simply  remittent,  Avith  great  difierences  in  the  morning  and  evening 
temperature  of  the  body,  a  fever  with  steep  curves.  According  to  my 
idea,  this  hectic  or  consumptive  fever  results  from  continvxed  absorp- 
tion of  the  products  of  inflammation,  especially  of  disintegration ; 
hence  it  is  most  frequent  and  most  intense  from  rapid  breaking  down 
of  the  inner  walls  of  large  abscesses,  and  in  rapid  progressive  ulcera- 
tion. This  fever  often  runs  its  course  with  rapid  emaciation,  night- 
sweats,  and  diarrhoea.  Few  patients  stand  such  chronic  suppurative 
fever  long ;  though  I  observed  a  boy  fourteen  years  old,  with  a  fistula 
remaining  after  resection  of  the  head  of  the  femur  and  general  larda- 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS.  451 

ceous  disease,  a  whole  year,  during  whicli  he  had  a  continued  febris 
reraittens ;  he  finally  died  from  general  dropsy. 

The  course  of  chronic  inflammation  may  be  classed  under  two  gen- 
eral heads.  In  the  first  case,  even  the  commencement  of  the  disease 
IS  indistinct,  and  can  scarcely  be  stated  with  any  certainty  by  the  pa- 
tient. Sometimes  it  is  a  swelHng,  a  moderate  pain,  or  a  slight  dis- 
turbance of  function  that  has  called  attention  to  a  morbid  state.  Cases 
which  have  begun  so  insidiously  usually  maintain  this  character  in 
their  further  course.  In  other  cases,  the  chronic  inflammation  is  a 
remnant  of  an  acute  process ;  the  chronic  course  is  interrupted  from 
time  to  time  by  acute  attacks,  with  fever.  We  can  say  least  that  is 
definite  about  the  duration  of  chronic  inflammation  in  general,  as 
this  above  all  things  depends  on  the  exciting  causes,  to  which  we 
shall  soon  come.  I  only  entreat  you  to  bear  in  mind  that  chronic 
inflammation,  like  the  acute,  has  a  tendency  to  terminate,  to  have  a 
typical  end,  for  the  new  formation  never  goes  beyond  the  develop- 
ment of  certain  characteristic  metamorphoses  of  tissue,  which  lead 
to  development  of  connective  tissue,  or  of  a  cicatrix  in  some  way, 
unless  the  diseased  tissue  is  destroyed  by  disintegration.  Why  it  is 
important  to  remember  this  will  be  clearer  to  you  when  we  treat  of 
the  limitation  of  other  new  formations,  such  as  actual  tumors.  Of 
course  the  new  formation  attains  no  typical  end  when  its  causes  can- 
not be  removed,  or  do  not  spontaneously  disappear,  and  when  organs 
are  destroyed  that  are  necessary  to  life,  or  when  the  strength  is  ex- 
hausted by  suppuration. 


LECTURE    XXIX. 

fteneral  Etiology  of  Chronic  Inflammation. — External  Continued  Irritation.— Causes  m 
the  Body. — Empirical  Idea  of  Diathesis  and  Dyscrasia.— General  Symptomatology 
and  Treatment  of  Ivlorbid  Diatheses  and  Dyscrasia3.  1.  The  Lymphatic  Diathesis 
(Scrofula) ;  2.  Tuberculous  Dyscrasia  (Tuberculosis) ;  3.  The  Arthritic  Diathesis  ; 
4.  The  Scorbutic  Dyscrasia  ;  5.  Syphilitic  Dyscrasia. 

To-DAT  we  come  to  one  of  the  most  important  parts,  not  only  of 
this  section,  but  of  all  medicine,  that  is,  to  the  causes  of  chronic  in- 
flammation. We  saw  how  acute  inflammation  resulted  from  an  irri- 
tant acting  once,  and  varied  according  to  the  anatomical  condition  of 
the  irritated  part,  and  the  natvu-e  and  extent  of  the  irritation,  but  that 
it  ran  a  relatively  short  and  typical  course.  Now  we  have  to  deal 
with  inflammations  that  last  several  months  or  years  ;  here  there 
must  be  a  continued  cause,  a  long-acting  irritation,  or  some  abnormal 
reaction  to  simple  irritation.     These  continued  irritations  may  be  of 


452  CAUSES  OF  CHRONIC  INFLAMMATION. 

a  jjurely  local  character ;  let  us  consider  them  for  a  moment.  When 
small  animals,  like  the  itch-insect,  take  up  their  abode  in  the  skin,  as 
they  dig  burrows  like  a  badger's  in  the  superficial  layers  of  the  cutis, 
lay  eggs,  and  there  lead  their  laborious  life,  they  cause  constant  irri- 
tation of  the  skin ;  to  this  is  added  the  scratching,  and  a  chronic  in- 
flammation of  the  skin  is  thus  caused  and  kept  up.  If  spores  of 
fungus  locate  in  the  epidermis,  and  there  begin  to  grow  and  to  mul- 
tiply to  millions  of  small  vegetable  organisms,  the  skin  will  be  placed 
in  a  state  of  continued  irritation  by  these  little  foreigners  ;  and  va- 
rious chronic  cutaneous  eruptions  will  result,  such  as  favus,  herpes 
tonsurans,  pityriasis  versicolor,  etc.  If  a  pressure  or  friction  act 
moderately  but  continuously  on  the  skin,  it  also  is  a  chronic  irritation, 
which  is  particularly  apt  to  induce  thickening  of  the  part  of  skin  af- 
fected. The  callous  spots  on  the  heel  and  many  corns  are  the  result 
of  the  continued  friction  and  pressure  induced  by  our  modern  foot- 
coverings.  In  the  same  way  the  workman  who  uses  axe  and  hammer 
a  great  deal  has  callosities  in  the  liand,  the  shoemaker  has  them  on 
the  outer  side  of  the  little  finger  and  hand  where  he  daily  draws  on 
the  pack-thread,  etc.  [We  see  the  same  thing  much  more  markedly 
on  the  side  of  the  left  thumb  and  forefinger  in  plasterers,  from  hold- 
ing their  plaster-board ;  and  at  the  upper  and  posterior  part  of  the 
front  leg  of  some  horses,  from  lying  on  their  iron  shoes.]  Sometimes 
foreign  bodies  in  the  tissue  keep  up  a  continued  chronic  irritation  in 
the  surrounding  parts.  Continued  or  often-repeated  chemical  irrita- 
tion of  the  tissue  may  also  induce  chronic  inflammation  ;  for  instance, 
chronic  gastric  catarrh  may  be  caused  by  the  repeated  use  of  schnaps 
or  strong  liquors.  Continued  stagnation  of  blood  and  lymph,  as 
well  as  their  coagulation  in  the  vessels,  first  induces  hyperplasia  of 
the  walls  of  the  vessels,  and  of  the  parts  immediately  around  them, 
distention  and  tortuosity  of  the  vessels,  and  thickening  of  the  tissue ; 
the  skin  of  the  leg  is  particularly  exposed  to  this  disease  when  there 
is  any  continued  opjjosition  to  the  escape  of  venous  blood  from  the 
extremity. 

When  we  have  to  treat  chronic  inflammations  that  may  be  traced 
to  such  external  continued  irritations,  of  which  many  more  illustra- 
tions might  be  given,  the  results  will  be  favorable.  We  get  rid  of 
the  animal  or  vegetable  parasites,  the  foreign  bodies,  the  continued 
pressure,  chemical  influences,  etc.,  and  the  chronic  inflammation  will 
disappear  spontaneously.  So  far  we  have  supposed  a  local  irritation 
acting  continuously  on  healthy  tissue ;  if  you  suppose  a  tolerably  se- 
vere irritation  acting  once  on  a  tissue  already  diseased,  you  cannot 
expect  the  conditions  to  prove  as  favorable  as  in  a  simple  traumatic 
inflammation  of  healthy  tissue ;  but  it  is  probable  that  the  results. 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS.  453 

even  of  the  single  imtation,  will  be  different,  possibly  more  continued, 
because  the  conditions  in  the  tissue  will  not  be  so  favorable  for  typical 
removal  of  the  disturbance.  SupjDose  a  portion  of  skin  already  suf- 
fering- from  chronic  inflammation  to  be  superficially  contused,  this  sin- 
gle irritation  may  induce  chronic  svippuration,  or  even  progressive  ul- 
ceration, which,  under  normal  conditions,  would  quickly  have  gone  on 
to  new  foi'mation  of  epidermis  and  healing. 

Tlie  cases  where  we  find  such  purely  local  causes  for  the  origin 
and  continuance  of  chronic  inflammation  are  comparatively  rare.  In 
the  great  majority  of  cases  the  cause  is  not  so  evident;  the  case 
must  be  watched  and  tried  in  various  ways  before  we  can  obtain  any 
clew  to  the  etiology  of  most  chronic  inflammations  and  diseases.  We 
have  not  here  mentioned  miasm  and  contagion  from  the  domain  of 
general  etiology ;  and  we  may  leave  them  out  of  the  question,  for 
there  is  nothing  to  show  that  chronic  inflammation  may  arise  from  a 
single  action  of  contagion  or  miasm.  It  is  true  there  are  chronic 
malarial  diseases,  such  as  intermittents,  etc. ;  but  there  the  cause  of 
injury  acts  continuously,  and  not  unfrequently  the  disease  can  only  be 
cured  by  removing  the  patient  from  the  miasmatic  atmosphere ;  hence 
this  case  corresj)onds  to  a  continued  external  irritation.  The  same  is 
true  of  repeatedly  catching  cold,  where  the  new  attack  affects  the 
body  already  diseased,  and  thus  induces  chronicity  of  the  process. 
But  all  this  does  not  suffice  for  the  etiology  of  chronic  inflammations; 
we  mvxst  also  look  for  the  causes  in  certain  congenital  or  developed 
conditions  of  the  whole  body.  Let  us  hear  what  experience  teaches 
on  this  subject. 

On  careful  observation  we  first  notice  that  certain  forms  of  chronic 
inflammation  constantly  recur  in  certain  organs  and  certain  parts  of 
the  body ;  that  at  the  same  time  they  show  themselves  chiefly  at  cer- 
tain ages  and  in  persons  presenting  some  similarities  in  their  external 
conditions.  Thus  we  see  children  of  the  same  class,  who  are  pecu- 
liarly disposed  to  chronic  swelling  and  suppuration  of  the  lymphatic 
glands,  joints,  and  bones,  other  persons  who  are  chiefly  affected  by 
insidious  inflammation  of  the  lungs,  others  who  are  particularly  liable 
to  colds  and  have  pains  in  the  different  muscles  and  joints.  We  also 
see  that  such  persons,  who  are  constantly  being  attacked  in  the  same 
way,  transfer  their  individual  pathological  pecuharities  to  their  de- 
scendants ;  that  those  leaving  such  legacies  have  in  their  turn  received 
them  from  their  fathers  or  mothers.  To  obtain  some  clear  idea  of 
:ndividual  morbid  predispositions  in  this  chaos,  persons  predisposed 
to  certain  chronic  diseases  were  divided  into  groups  ;  thus,  in  a  purely 
empirical  manner,  men  were  divided,  according  to  morbid  dispositions 
or  diatheses,  hito  lymphatic,  scrofulous,  tuberculous,  rheumatic,  etc. 


454  CAUSES   OF   CHRONIC   INFLAMMATION. 

terms  which  at  first  merely  meant  that  the  scrofulous,  for  instance, 
were  especially  jDredisposed  to  glandular  diseases ;  the  tuberculous  to 
the  development  of  ulcerating  nodules,  etc.  Subsequently  this  group- 
ing was  carried  further,  and  it  was  concluded  that  a  certain  morbid 
condition  of  the  physiological  processes  of  the  entire  body  must  He  at 
the  root  of  such  predis^^ositions,  A  morbid  material,  or  essence,  a 
materia  peccans,  was  supposed  to  exist  in  the  body ;  the  most  natural 
bearer  of  this  was  the  blood,  for  this  passed  through  the  entire  body, 
and  its  condition  certainly  gave  a  measure  for  the  more  or  less  normal 
or  pathological  condition  of  the  entire  body.  The  woi'd  dyscrasia  (a 
bad  mixture)  indicated  such  a  pathological  condition  of  tlie  blood ; 
hence  a  scrofulous,  tuberculous,  etc.,  dyscrasia  were  sj^oken  of.  It  is, 
however,  a  strange  idea  to  burden  the  blood  alone  with  the  patho- 
logical changes  of  the  whole  body,  and  assume,  as  it  were,  that  infec- 
tion of  the  whole  body  resulted  from  it.  This  could  only  be  acknowl- 
edged in  cases  where  an  abnormal  material  was  introduced  into  the 
blood  from  without,  as  we  have  seen  to  be  the  case  in  poisoned 
wounds.  But  this  is  not  the  case  in  the  dyscrasias  under  consideration, 
or  at  least  it  is  only  partially  so  ;  but  the  morbid  dispositions  develop 
in  the  body  itself  from  causes  little  known,  if  they  be  not  handed 
down  as  an  inheritance  from  the  parents.  The  blood  is  no  more 
absolutely  stable  than  any  other  tissue  of  the  body ;  it  is  constantly 
being  renewed,  partly  used  up  and  again  renewed,  etc.  ;  we  do  not 
certainly  know  the  source  for  the  renewal  of  the  blood-corpuscles ; 
you  know  from  physiology  that  the  serum  of  the  blood  is  constantly 
being  regenerated  from  the  lymph,  and  this  again  from  the  chyle- 
vessels  of  the  intestines,  and  you  also  know  that  fluid  constituents 
from  the  blood  are  excreted  by  kidneys,  lungs,  and  skin.  How  little 
we  know  of  these  things,  and  how  complicated  even  these  little  affairs 
are  !  I  lead  you  to  this  consideration  to  add  that  normal  blood  can 
only  form  from  a  healthy  body,  and  the  reverse  ;  hence  that  we 
cannot  physiologically  speak  of  a  one-sided  disease  of  the  blood.  But 
there  would  be  no  use  waging  war  against  and  trying  to  root  out  the 
words  dyscrasia  and  diathesis,  now  firmlj'  embedded  in  medical  lan- 
guage. It  would  do  science  no  harm  to  use  them  forever  with  the 
above  meaning ;  we  must  have  a  name  for  these  things,  for  they  are 
not  myths,  but  are  facts  that  have  been  observed  for  centuries,  although 
their  significance  has  varied  greatly.  We  may  go  too  far  in  classify- 
ing persons  in  this  matter,  if  we  ascribe  to  ever}'  one  a  pathological 
diathesis,  or  try  to  place  every  patient  in  one  of  the  cliief  divisions. 
Although  there  might  theoretically  be  a  certain  amount  of  correctness 
in  supposing  that  in  our  present  state  of  cultivation  there  was  no  such 
thing  as  an  absolutely  healthy  man,   still,  it  would  be  very  senseless 


CHROXIC   INFLAMMATION   OF   THE   SOFT   PARTS.  455 

to  try  to  maintain  this  in  practice.  And  you  must  not  suppose  that 
it  is  always  so  easy  to  ck\ss  every  patient  in  certain  groups,  just  as 
plants  are  analyzed  and  their  systems  determined,  for  all  classes  of 
men  may  breed  with  each  other ;  moreover,  some  abnormally-formed 
individuals  may  become  perfectly  normal  in  the  course  of  time,  and 
the  reverse ;  thus  a  number  of  middle  forms  naturally  result,  which 
defy  any  classification.  There  are  now,  as  there  have  at  all  times 
been,  phj'sicians  who  are  too  skeptical  about  the  existence  of  a  gen- 
eral morbid  disposition  to  certain  forms  of  disease,  and  only  acknowl- 
edge local  and  j^artly  only  accidental  irritations  as  causes.  Such  a 
hyper  skeptical  current  ran  through  modern  medicine  a  short  time 
since,  and  was  perfectly  justified,  for  the  crasis  doctrine  had  become 
so  luxuriant,  that  there  was  scarcely  a  variety  of  inflammation,  scarcely 
a  disease,  in  fact,  which  was  not  based  on  some  specific  crasis.  Who- 
ever observes  independently  and  carefully,  and  at  the  same  time  has 
the  ojDportunity  of  seeing  a  variety  of  patients,  will  certainly  arrive 
at  the  correct  view  in  the  course  of  time,  and  will  neither  throw  him- 
self too  unreservedly  into  the  arms  of  the  crasis  theory,  nor  set  aside, 
as  illusions  and  deceptions,  the  experiences  of  centuries.  It  is  a  ques- 
tion whether  it  be  of  any  practical  value  to  use  such  terms  as  scrofu- 
lous or  syphilitic  inflammation,  if  it  would  not  be  better  to  regard 
the  chronic  inflammatory  processes  %vithout  any  regard  to  their  origin. 
The  future  will  decide  this  question ;  at  present  I  deem  it  my  duty  as 
teacher  to  clear  your  views  on  these  points  as  much  as  possible,  and 
to  place  you  in  a  position  to  be  able  to  understand  all  your  colleagues 
speaking  on  these  subjects,  no  matter  to  what  school  they  belong. 
But  enough  of  this  general  explanation  ;  let  us  draw  a  brief  sketch  of 
the  different  diatheses  and  dyscrasias  : 

1.  The  lyynphatlc  or  scrofulous  diathesis  {scrofula).  This  tendency 
to  disease  exists  chiefly  during  childhood,  though  more  advanced  ages 
are  not  free  from  it.  Persons  with  this  diathesis,  especially  children, 
are  greatly  disposed  to  chronic  inflammatory  swellings  of  the  lym- 
phatic glands,  even  after  inconsiderable  ii-ritations,  to  certain  inflam- 
mations of  the  skin  (eczema,  impetigo),  especially  of  the  face  and 
head,  to  catarrhal  inflammations  of  the  mucous  membranes,  especially 
of  the  conjunctiva,  more  rarely  of  the  intestinal  canal  and  respiratory 
organs,  to  chronic  inflammations  of  the  periosteum  and  of  the  synovial 
membranes  of  the  joints.  As  regards  the  swelling  of  the  lymphatic 
glands,  especially  of  the  submaxillary  and  occipital,  it  has  been  asserted 
that  it  is  merely  a  result  of  irritation  from  dentition,  or  of  the 
eczematous  eruptions  on  the  head,  of  the  inflammations  of  the  eye, 
ear,  etc.  ;  this  is  partly  correct,  but  even  taking  this  view,  that  all 
swellings  of  the  lymphatic  glands  are  secondary,  even  then  for  the 


456 


SCROFULA. 


glands  to  swell  after  dentition,  for  instance,  there  must  be  an  abnor- 
mal irritability  of  the  lymphatic  system  such  as  does  not  exist  in  all 
children  •  moreover,  such  local  irritations  cannot  always  be  found  for 
the  affections  of  the  bronchial  and  mesenteric  glands,  which  are  almost 
as  frequent.  It  is  also  a  morbid  state  for  the  swellings  of  the 
lymphatic  glands  to  last  longer  than  the  irritation,  and  even  subse- 
quently to  increase  without  apparent  cause.  It  may  be  acknowledged 
that  some  of  the  above  affections — for  instance,  part  of  the  scrofulous 
diseases  of  the  joints — are  caused  by  injuries,  contusions,  etc. ;  but  the 
fact  that  they  take  a  chronic  and  to  some  extent  entirely  peculiar, 
constant  course,  is  due  to  abnormal  condition  of  the  tissue,  which  ab- 
normal condition  is  so  spread  over  the  entire  body  that  it  cannot  be 
regarded  as  a  purely  local,  but  must  be  considered  a  universal  condi- 
tion. Various  attempts  have  been  made  to  explain  this  local  and  gen- 
eral abnormity,  especially  to  refer  the  "  chronicity  "  to  a  continuance 
of  the  irritation,  so  as  to  escape  the  enigma  of  an  organism  reacting 
differently  to  one  irritant  from  what  it  does  to  another.  Hence  it 
has  been  assumed  that  the  matters  formad  by  a  chemical  change  in 
the  tissues,  from  whatever  cause,  were  not  taken  up  by  the  lymph- 
and  blood-vessels  and  removed  from  the  diseased  organ,  but  remained 
there  and  induced  continued  inflammatory  irritation.  I  am  far  from 
denying  that  this  takes  place  occasionally ;  but  even  if  it  were  always 
true,  the  peculiarity  just  mentioned  of  this  or  that  organ  still  remains 
abnormal  in  these  persons.  In  short,  we  do  not  tluis  escape  the  fact 
that  tliese  persons  differ  from  the  majority  either  in  cei'tain  tissues 
or  in  toto.  Cliil'lren  fall  times  without  number  on  knee,  hip,  or 
elbow,  without  auv  disease  resulting,  or  else  the  effects  pass  off  in  a 
few  days,  even  without  treatment  and  when  there  has  been  consid- 
erable bruising,  as  shown  by  the  extensive  extravasation,  swelling, 
and  pain.  But  even  after  sliglit  injuries  some  children  have  chronic 
inflammations  of  the  joints  ;  these  are  exceptions;  there  is,  however, 
no  objection  to  regarding  them  as  a  peculiar  pathological  race.  At- 
tempts have  been  made  to  diagnose  the  scrofulous  diathesis  from  the 
general  appearance  and  condition  of  the  child.  The  following  is  the 
picture  usually  drawn  of  a  scrofulous  child  :  blond  hair,  blue  eyes, 
very  white  skin  wilh  thick  cellular  membrane,  thick  lips,  pot-belly, 
voracious  appetite,  and  tendency  to  constipation  {torpid  scrofula). 
In  practice  you  will  meet  some  of  the  originals  of  this  })ortrait,  but 
you  will  see  many  other  cases  not  at  all  like  it,  which  nevertheless 
suffer  from  typical  scrofula,  I  do  not  attach  much  importance  to 
these  external  symptoms.  In  regard  to  the  course  and  terminations 
of  chronic  inflammation  in  scrofulous  children,  Ave  may  make  the  fol- 
lowing remarks  :  In  a  few  cases  the  chronic  inflammatorv  swelling 


CHRONIC  IXFLAMMATIOX   OF   THE   SOFT   PARTS.  457 

sooner  or  later  subsides  entirely,  and  the  parts  become  perfectly  nor- 
mal. The  course  with  suppuration  is  the  most  frequent,  and  accord- 
ing to  the  special  nature  of  the  case  this  may  be  quite  acute,  as  it  is 
in  inflammation  of  the  submaxillary  glands  and  in  inflammations  of 
the  joints.  Often  the  disease  remains  chronic  for  years  ;  abscesses, 
fistulas,  ulcers,  etc.,  form.  Early  suppuration  occurs,  especially  in 
somewhat  emaciated,  debilitated,  badly-nourished  children,  who  are 
very  liable  to  fever  [erethitic  scrofula),  and  its  prognosis  is  very  bad. 
The  termination  of  the  inflammation  in  caseous  degeneration  is  not 
rare  ;  it  is  particularly  frequent  in  the  lymphatic  glands  ;  of  course  it 
must  have  a  very  bad  eff'ect  on  the  general  nutrition,  when  the  mesen- 
teric glands  are  degenerated  in  this  way,  and  the  chyle-ducts  thus 
mostly  obstructed  ;  incurable  atrophy  of  the  entire  body  may  thus  be 
induced.  The  lymphatic  diathesis  is  in  most  cases  congenital,  and  is 
transmitted  from  generation  to  generation  ;  but  it  may  also  be  devel- 
oped by  improper  modes  of  life.  Among  the  most  injurious  causes 
are  given  :  chief  or  exclusive  diet  of  potatoes.  Hour,  or  sour  bread ; 
unhealthy,  damp  dwellings  ;  lack  of  cleanliness,  fresh  air,  etc.  It  is 
indeed  difficult  to  prove  if  all  this  be  correct  ;  at  all  events,  if  the 
above  causes  always  induced  scrofula,  it  Avould  be  much  more  frequent 
than  it  now  is  among  the  poor. 

To  state  in  a  few  words  what  is  at  present  understood  by  a  lymphat- 
ic constitution  or  scrofula,  it  may  be  considered — 1,  as  a  disposition 
to  chronic  inflammation  of  the  skin,  bones,  and  joints,  in  which  the 
inflammation  may  lead  to  development  of  granulations,  of  pus,  and 
to  caseous  degeneration ;  2,  as  existing  when  swellings  of  the  lym- 
phatic glands,  even  when  induced  by  temporary  irritation,  continue 
long  in  the  same  state,  or  even  increase  without  new  peripheral  irri- 
tation. 

We  shall  here  pass  at  once  to  the  treatment  of  scrofula  in  general. 
First  of  all,  the  diet  should  be  regulated  ;  good  animal  food,  eggs,  and 
milk,  well-baked  wheaten  bread,  occasional  baths,  residence  in  fresh, 
healthy  air,  a  hardening  mode  of  life,  are  the  most  important  reme- 
dies, but  from  the  circumstances  they  are  often  the  most  difficult  to 
employ;  in  prescribing  the  diet,  special  attention  must  often  be  paid 
to  the  individual  case,  especially  as  to  whether  there  is  a  tendency  to 
lardaceous  disease  or  atrophy,  whether  the  digestive  organs  are  nor- 
mal, or  were  ruined  in  youth  by  improper  diet.  As  the  disease  is 
very  common  among  the  poor  (without  the  rich  being  free  from  it, 
however),  these  dietetic  and  hygienic  rules  are  particularly  difficult  to 
follow.  The  number  of  internal  anti-scrofulous  remedies  is  very  great ; 
the  object  is  not,  as  was  formerly  supposed,  to  introduce  a  specific 
remedy  as  an  antidote  to  some  unknown  poison  circulating  in  the 


458 


SCROFULA. 


blood,  for  the  latter  does  not  exist ;  but  the  treatment  should  be  purely 
symptomatic,  and  usually  general.  From  the  above,  you  see  that 
scrofula  is  not  a  materia  peccans  in  the  blood,  but  only  a  debility  of 
the  organization  in  some  direction,  a  more  or  less  intense  predisposi- 
tion to  peculiar  forms  of  disease.  This  is  a  decided  dilTerence  from, 
and  an  advance  beyond,  the  old  view  of  the  disease.  Frjm  my  ex- 
planation you  may  also  understand  those  recent  skeptics  who  think 
that  all  chronic  inflammations  in  children  are  of  similar  origin,  and 
that  it  is  consequently  unnecessary  in  each  case  of  chronic  inflamma- 
tion of  the  lymjDhatic  glands,  or  in  articular  inflammation,  to  add  that 
it  is  scrofulous  or  depends  on  a  lymphatic  diathesis.  Possibly  these 
expressions  may  disappear  in  the  course  of  time,  as  they  will  be  ren- 
dered unnecessary  by  greater  clearness  of  ideas,  but  it  is  not  correct 
to  say  that  all  chronic  inflanunations  in  children  have  the  same  origin, 
for  some  of  them  may  be  due  to  hereditary  or  developed  syphilis;  and 
in  adults  there  are  many  other  constitutional  predispositions  besides 
those  that  have  hitherto  been  termed  scrofulous  or  tuberculous,  and 
which  consist  in  the  predisposition  to  chronic  inflammations  ending  in 
suppuration,  caseous  degeneration,  and  ulceration.  It  seems  to  me 
that  there  can  be  no  doubt  that  these  processes  are,  to  a  certain  ex- 
tent, opposed  to  other  forms  of  chronic  inflammation — for  instance, 
to  those  depending  on  interstitial  proliferation  of  connective  tissue 
(cirrhosis  of  the  liver,  morbus  Brightii,  gray  degeneration  of  the 
medulla  spinalis,  etc.). 

Many  things  have  been  tried  to  improve  the  lymphatic  diathesis. 
Formerly  ])urgatives  were  occasionally  given,  and  in  England  particu- 
larly small  doses  of  mercury  were  administered  ;  this  is  well  suited  to 
fat  scrofulous  children  ;  burnt  sponge,  folia  juglandis  regime,  herba 
jacea,  acorn-coff'ee,  and  bitter  medicines,  were  recommended,  and  are 
still  used.  At  present,  cod-liver  oil  is  most  used  as  an  anti-scrofuletic, 
as  it  is  not  only  considered  to  have  a  specific  action  against  the  scrofu- 
lous diathesis,  but  is  very  properly  prized  as  exceedingly  nutritious, 
and  hence  is  especially  used  in  emaciated  scrofulous  children  ;  in  fat 
children  it  might  even  prove  injurious.  Some  of  the  preparations  of 
iodine  act  very  well  in  scrofula  ;  but  they  should  be  employed  care- 
fully, and  in  fat  rather  than  in  atrophic  children  ;  iodide  of  iron  is  best 
in  pale  fat  children,  with  fungous  inflammations  of  the  joints.  The 
easily-digested  preparations  of  iron  are  very  valuable  remedies  in 
scrofula  patients  with  anaemia.  Salt-water  baths  also  act  beneficially  ; 
these  may  either  be  used  at  the  springs,  in  Germany,  for  instance,  at 
Kreuznach,  Rheme,Wittekind,  Coblenz,  Tolz,  Reichenhall ;  in  Austria, 
at  Hall,  Tsclil ;  hi  Switzerland,  at  Rheinfelden,  Schweizerhall,  Lavey,  or 
Bex ;  or,  they  may  be  prepared  at  home  by  adding  from,  according 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS.  459 

to  the  size  of  the  bath,  one  to  three  pounds  of  salt  to  a  warm  bath. 
For  a  large  child,  sea-baths  may  be  recommended ;  for  weakly  chil- 
dren, warm  baths  with  the  addition  of  malt  and  aromatic  herbs.  In 
fat  scrofulous  children,  JSfiemeyer  recommends  wrapping  the  whole 
body  in  wet  sheets ;  I  have  seen  good  results  from  this  in  some  cases. 
Some  physicians  also  recommend  sulphur-springs,  especially  the  hot 
ones,  in  scrofulous  diseases  of  the  joints ;  so  far,  I  have  seen  more 
harm  than  good  from  them.  You  see  there  is  no  lack  of  remedies  ; 
still  we  rarely  succeed  in  improving  the  constitution  by  them,  and  cau' 
not  prevent  relapses  in  all  cases.  Sometimes,  too,  the  local  process 
attains  such  a  grade  as  to  be  of  itself  dangerous  to  life,  and  the  local 
remedies  must  be  mostly  relied  on.  As  before  stated,  the  tendency 
to  these  diseases  greatly  decreases  in  the  course  of  years ;  but  many 
children  die  of  the  diseases  of  the  bones  and  joints, 

2.  The  tuberculous  dyscrasia.  Tuberculosis.  The  name  of  this 
disease  comes  from  tuberculum,  the  nodule,  because  chronic  inflam- 
mations due  to  this  disease  appear  as  small  nodules,  or  tubercles,  at 
first  scarcely  as  large  as  a  millet-seed,  often  microscopic.  If  you 
analyze  one  of  these  nodules  with  the  microscope,  you  find  it  to  con- 
sist of  a  number  of  medium-sized,  round  cells,  which  increase  in  the 
periphery  of  the  nodule,  while  in  its  midst  the  short-lived  cells  have 
already  broken  down  to  a  fine,  molecular,  dry  pulp,  which,  when  the 
nodule  is  very  large,  becomes  j'ellow  and  caseous. 

The  recent  investigations  of  Schiq)pel,  Lanffhans,  Itlndfleisch, 
and  others  agree  that  large  multinucleated  masses  of  protoplasm,  so- 
called  giant  cells,  are  often  found  in  the  centre  of  young  tubercles  ; 
we  shall  speak  of  these  further  when  describing  the  new  formation 
cf  bone.  The  nuclei  in  the  giant  cells  of  tubercle  are  often  exqui- 
sitely arranged  about  the  periphery.  But  these  giant  cells  do  not 
always  occur  in  tubercles.  We  often  see  in  the  peritoneum  an  in- 
discriminate grouping  of  large  and  small  cells  as  a  commencement 
of  tubercle;  and  near  these  distinctly  round  or  very  irregular  but 
sharply-bounded  new  formations  there  are  more  diffuse  (tuberculous) 
infiltrations,  which  can  scarcely  be  distinguished  from  ordinary  in- 
flammatory infiltration,  except  by  the  fact  that  the  cells  are  nearly 
double  the  size  of  wandering  cells  which  form  the  first  cellular  infil- 
tration in  acute  inflammation. 

A  great  peculiarity,  especially  noticed  by  Rindfleisch,  is  that  tu- 
bercle often  develops  on  and  in  the  walls  of  small  arteries  and  lym- 
phatics, but  very  rarely  in  veins. 

There  are  various  views  about  the  origin  of  the  cells  which  form 
tubercles.  If  they  are  wandering  cells,  they  must  enlarge  very  rap- 
idly soon  after  their  escape  from  the  capillaries  and  veins ;  on  the 


460 


TUBERCULOSIS 


•whole,  modern  observers  are  little  inclined  to  this  view.  MlndflelscJi, 
Kimdrat,  and  others  hold  that  tubercle-cells  develop  mostly  from 
proliferation  of  endothelium,  especially  that  of  the  blood-vessels, 
lymphatic?,  and  serous  membranes.  Mindfleisch  thinks  they  may 
also  develop  from  the  muscle-cells  of  the  arteries;  Ziegler  has 
proved  that  they  may  result  from  confluence  of  wandering  cells. 


Fig.  71  A. 


Giant  cells  from  tubercle  in  various  stages  of  development.     After  Langhans.    Magnified  about  400. 


Regarding  the  subsequent  fate  of  these  small  neoplasia,  the  most 
essential  and  peculiar  thing  about  them  is  that  vessels  do  not  de- 
velop in  them  an}'-  more  than  in  purely  epithelial  neoplasia,  although 
their  periphery  is  very  vascular.  Very  rarely  cases  occur  where  the 
tubercles  gradually  become  filament-nodules.  While  every  other 
neoplasm  is  accompanied  by  growth  of  vessels,  in  tubercles  this  is 
wanting  entirely,  as  has  been  lately  shown  again  by  Mindfleisch, 
Heitzmann,  and  others.  The  result  of  this  is  that  the  young  neo- 
plasia cannot  live  long ;  it  dies  in  the  centre,  but  the  periphery  sur- 
vives. The  dead  centre  occasionally  breaks  down  into  a  fine,  punc- 
tate, amorphous  substance,  which  to  the  naked  eye  appears  as  a 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS. 
Fig.  71  b. 


461 


a,  Minute  tubercles  in  tbe  peritoneum,  b.  Minute  tubercles  on  a  cerebral  artery,  a  and  6  slightly  mag- 
nified from  preparations  of  EiiiilfleUioh,.  c,  Development  of  minute  tubercles  in  the  peritoneum. 
After  Kandrat.    Magnified  500. 

dry,  cheesy  pulp  ;  in  short,  as  a  result  of  its  lack  of  blood-vessels, 
the  tubercle  undergoes  cheesy  degeneration.  Possibly  the  tubercle 
might  enlarge  ad  infinitum  by  new  cellular  infiltration  of  the  tissue 
around  the  primary  f.>cus,  but  this  rarely  happens.  The  large  cheesy 
deposits  found  in  the  brain,  testicle,  etc.,  in  most  cases  result  from 
confluence  of  numerous  small  nodules,  of  which  we  often  find  num- 
bers in  the  vicinity  of  large  caseous  nodules. 

This  brings  us  to  the  relation  of  the  tissue  to  the  tubercle  scat- 
tered through  it.  I  would  here  remark  that  tlie  miliary  nodules 
usually  appear  in  large  numbers  in  the  organ  or  part  affected.  Just 
around  the  tubercle  there  is  generally  a  subacute  inflammation  with 
free  cell-infiltration  and  vascularization ;  this  may  lead  to  suppura- 
tive softening  of  the  tissues,  chronic  abscesses,  and  ulceration  ;  thus 
a  cavity  is  formed  which  contains  pus,  softened  shreds  of  tissue,  and 
caseous  tubercle.  The  inflamed  parts  around  the  tubercle  may  be 
drawn  into  the  caseous  degeneration,  and  a  large  cheesy  deposit 


462 


TUBERCULOSIS. 

Fig.  71  c. 


a,  Minute  tubercle  of  a  cerebral  artery.  Maprnified  lOO.  6,  Commencement  of  the  cellular  growth  in 
one  of  the  small  cerebral  arteries. "  Jlag-nitled  about  1.00 ).  ( I  do  not  think  it  can  be  proved  whether 
the  multinucleated  cells  are  wandering  connective-tissue,  endothelial,  or  muscle  cells,  or  whether 
they  are  due  to  the  transformation  of  the  intima  to  protoplasm.)  Both  drawings  are  from 
preparations  of  Rindfleisch. 

forms,  which  shall  contain  the  primary  tubercle  ;  this  may  subse- 
quentlj'  soften  by  peripheral  suppuration,  or  after  encapsulation  may 
become  calcareous.  If  tubercles  form  in  mucous  membranes,  as  in 
the  larynx,  intestine,  ureters,  bladder,  or  uterus,  besides  the  tuber- 
culous infiltrations  and  ulcerations  there  is  purulent  catarrh,  with 
free  detachment  of  epithelium,  especially  in  the  pulmonary  alveoli 


CHRONIC   IXFLAMMATIOX   OF  THE   SOFT   PARTS.  463 

(desquamative  pneumonia,  Buhl).  In  all  of  these  cases  the  diseased 
part  may  be,  but  unfortunately  rarely  is,  encapsulated  by  firm  con- 
nective tissue,  after  undergoing  metamorphosis ;  and  after  evacuation 
or  calcification  of  the  contents,  the  capsule  may  shrink  to  a  firm  cic- 
atrix. But  in  serous  membranes,  and  especially  in  the  peritoneum, 
the  inflammation  caused  by  presence  of  tubercles  leads  at  once  to 
development  of  connective  tissue,  which  not  only  encapsulates  the 
nodules,  but  causes  such  an  intimate  adhesion  of  the  intestines  to 
each  other  and  to  the  walls  of  the  abdomen,  that  they  can  scarcely 
be  separated  on  autopsy. 

As  regards  the  occurrence  of  tubercles  in  difi"erent  organs,  none 
are  exempt,  though  some  are  more  predisposed  than  others.  Tuber- 
cles are  most  frequently  found  in  the  lungs,  especially  at  their  apices; 
there  are  usually  many  at  one  time ;  they  unite,  the  walls  of  the 
bronchi  are  implicated  in  the  process,  they  are  destroyed,  and  the 
caseous,  partially-softened  contents  of  the  tubercles  are  coughed  up; 
sometimes  blood-vessels  are  ruptured,  giving  rise  to  spitting  of 
blood  or  pulmonary  haemorrhage.  A  space  thus  left  by  softened 
tubercle  is  called  a  cavity.  It  is  not  our  object  to  enter  more  into 
detail ;  you  will  hereafter  learn  enough  of  this  unhappy  disease  in  the 
clinic.  Next  to  the  lungs,  the  most  frequent  location  of  the  disease 
is  in  the  laryngeal  mucous  membrane,  then  in  the  intestinal  mucous 
membrane,  even  in  the  rectum,  where  the  tuberculous  ulcers  and  ab- 
scesses also  acquire  a  surgical  interest.  Tubercles  also  occur  in  the 
bones,  especially  in  the  spongy  ones,  such  as  the  calcaneus,  bodies 
of  the  vertebrre,  and  upper  epiphyses  of  the  tibia.  Although  the 
lymphatic  glands  are  often  diseased  in  tuberculosis,  miliary  tubercle 
proper  is  hardly  ever  seen  in  them ;  still  Schuj)pel  found  them 
there  also. 

The  views  as  to  the  etiology  of  tuberculosis  have  changed  wonder- 
fully of  late  years.  Formerly  it  was  not  doubted  that  it  was  partly 
an  idiopathic  disease,  partly  due  to  hereditary  predisposition.  Hence 
we  spoke  of  a  tuberculous  as  we  did  of  a  scrofulous  diathesis,  and  the 
two  were  considered  as  related,  although  not  identical.  Laennec 
started  the  view  that  the  small  nodular  neoplasia  (gi'^-y  miliary  tuber- 
cles) were  the  primary  development,  and  by  confluence  and  growth  led 
to  the  destruction  of  the  affected  tissues.  The  division  of  tubercles 
into  miliary  gray  points  and  into  cheesy  nodules,  the  very  peculiar 
acute  miliary  tuberculosis,  the  connection  of  tuberculous  with  other 
and  especially  with  chronic  suppurative  inflammations  and  those 
tending  to  caseous  degeneration,  were  gradually  developed  and  in 
many  places  remain  obscure,  although  the  idea  of  tubercle  has  been 
rendered  more  limited  and  precise  by  F7rc/iO?c,  so  that  at  present 


464 


TUBERCULOSIS. 


every  new  formation  that  has  undergone  caseous  degeneration  is  not 
considered  as  tubercle.  It  was  reserved  for  Buhl,  by  careful  experi- 
ments, to  arrive  at  the  idea  that  acute  miliarj-  tuberculosis  was  the  pro- 
per type  of  tuberculous  disease;  he  found  it  mostly  combined  with  old 
caseous  or  purulent  inflammatory  foci  ;  he  made  the  bold  assertion 
that  it  always  resulted  from  absorption  of  substances  from  these  foci. 
According  to  this,  tuberculosis  was  an  infectious  disease,  a  sort  of 
nodular  exanthema  on  and  in  internal  organs,  caused  by  the  absorp- 
tion of  an  injurious  substance,  particularly  from  old  caseous  points  of 
inflammation  in  the  lymphatic  glands,  lungs,  bone,  etc.,  and  some  of 
these  particles  may  have  a  specific  infectious  action,  as  emboli  in  the 
lymph-  and  blood-vessels.  Investigations  of  late  years  have  shown 
that  many  destructions — in  the  lungs,  for  instance — which  previ- 
ously had  been  considered  due  to  miliary  tuberculosis  as  a  matter  of 
course,  are  inspissated,  caseous,  and  partly-softened  spots,  that  must 
be  regarded  as  the  result  of  a  simple  chronic,  ulcerative  inflammation, 
as  no  miliary  tubercles  are  found  in  them,  but  only  large-celled  infil- 
tration. It  seems,  indeed,  that  even  in  pulmonary  tuberculosis  the 
formation  of  true  tubercle  is  to  be  regarded  as  secondary  and  fre- 
quent, but  by  no  means  necessary'.  Niemeyer  deserves  great  credit 
for  his  practical  application  of  this  view,  according  to  which  a  diathe- 
esis  to  chro) lie  purulent  inflmninations  of  certahi  organs,  hut  not  the 
tuherctdous  infection,  toould  he  congenital.  This  view  is  of  late 
greatly  supported  by  the  fact  that  attempts  to  render  animals,  espe- 
cially Guinea-pigs  and  rabbits,  tuberculous,  have  succeeded.  In  these 
little  animals  irritation  of  very  short  duration  excites  inflammation  with 
caseous  purulent  products,  and  from  this  focus  results  a  tuberculous 
dyscrasia,  which  evinces  itself  in  the  production  partly  of  miliary  tuber- 
cles, especially  on  the  serous  membranes,  partly  of  yellow  nodules  in  the 
lung,  liver,  spleen,  etc.,  and  causes  death.  These  very  interesting  ex- 
periments, which  were  begun  by  Villemin,  and  repeated  by  Lehert  and 
Wyss,  Fox,  Klehs,  CoJinheim,  Waldenhurg,  Menzel,  and  others,  with 
the  same  result,  but  with  different  interpretations,  seem  to  me  to  prove, 
what  I  have  always  maintained,  that  tubercle  is  merely  a  peculiar 
form  of  inflammatory  new  formation  ;  that  is,  that  BuhVs  view  is 
conect.  But  it  is  important  to  remember  that  these  inoculations 
only  succeeded  in  animals  having  a  tendency  to  cheesy  degeneration, 
as  rabbits,  etc.  Mindfleisch  says  these  animals  become  tuberculous 
whenever  they  have  a  chronic  inflammation.  In  dogs  the  inoculation 
does  not  succeed. 

[The  tendency  for  patients  with  points  of  cheesy  degeneration 
to  become  tuberculous,  explains  the  presence  of  young  miliary  tu- 
bercles in  the  lungs  of  patients  with  advanced  phthisis  ;  the  latter 


CHRONIC   INFLAMMATION    OF   THE   SOFT  PARTS.  465 

occasioned  the  former.  A  long  step  in  the  etiology  of  phthisis  was 
made  when  Villemin,  from  numerous  experiments,  declared  the 
transmission  of  tuberculosis  from  one  person  to  another  ;  he  said  if 
tuberculous  matter  was  introduced  into  the  body  of  an  animal,  it 
acquired  true  tuberculosis.  It  made  no  diiference  if  the  introduc- 
tion was  by  inoculation,  injection,  or  feeding  ;  it  was  only  important 
that  the  tuberculous  matter  should  be  fresh  and  undecomposed. 

It  is  only  of  late  that  the  numerous  apparent  contradictions  in 
the  results  of  different  experimenters  have  been  explained.  First  it 
was  shown  that  the  introduction  of  indifferent  bodies  only  induced 
tuberculosis  when  the  animals  were  at  the  same  time  exposed  to 
other  opportunities  for  infection  with  tubercle.  It  was  found  that 
rabbits  became  tuberculous  in  the  laboratories  where  these  experi- 
ments were  made,  even  when  nothing  was  done  to  them  ;  when  not 
in  the  laboratory,  tuberculization  did  not  follow  inoculation  with 
indifferent  bodies,  and  they  could  be  inoculated  with  all  kinds  of 
caseous  inflammatory  products  without  showing  signs  of  tubercu- 
losis, but  that  certain  pathological  products  invariably  produced  it. 
It  makes  no  difference  whether  for  this  purpose  we  use  a  piece  of 
tuberculous  peritonceum,  pia  mater,  or  cheesy  portion  of  lung,  tes- 
ticle, or  lymphatic  gland  ;  always  within  a  short  time,  according 
to  Cohnheim  and  Salomonsen,  in  rabbits  the  twenty-first  day,  in 
Guinea-pigs  a  week  earlier,  there  was  an  eruption  of  tubercles,  when 
the  inoculation  was  made  from  man  to  the  animal  or  from  one  ani- 
mal to  another. 

From  these  undoubted  results  of  experiments  tuberculosis  must 
be  regarded  as  a  peculiarly  infectious  disease  ;  all  caseous  products 
do  not  induce  it,  only  those  are  active  that  had  previously  been 
regarded  as  products  of  tuberculous  neoplasia,  but  are  now  consid- 
ered the  cause.  Hence  the  views  held  originally  by  Laennec  and 
JiokitaiisA-t/  as  to  the  causal  relation  of  acute  miliary  tuberculosis 
and  tuberculous  infiltration,  again  took  position.  Tuberculosis  is 
excited  by  the  transfer  of  tuberculous  matter,  and  by  nothing  else. 

Observation  showed  that  not  only  specific  tuberculous  products, 
as  sputa,  infiltrated  tissue,  etc.,  proved  active,  but  investigation  of 
tuberculosis  in  cattle  (so-called  Perlsucht)  showed  that  feeding  on 
the  milk  of  cows  with  this  disease  could  transfer  it  to  other  animals  ; 
or  that  living  in  the  same  stall  with  them  would  communicate  the 
disease.  VUlemin.  has  found  that  dry,  dusty  tuberculous  matter  re- 
mained active,  so  it  was  natural  to  suppose  that  tuberculosis  in  man 
could  also  be  induced  by  a  material  and  probably  dust-like  conta- 
gion, and,  from  the  great  frequency  of  the  primary  disease  in  the 
lungs,  that  they  were  the  most  common  way  for  the  infection  to 
31 


466  TUBERCULOSIS. 

enter  the  body ;  hence  Cohnheim  called  it  an  inhalation-disease, 
although  the  virus  may  be  taken  in  by  the  intestines  and  other  ways. 

Transfer  of  the  disease  from  man  to  animals,  dogs,  rabbits,  etc., 
by  inhalation  of  finely-divided  products,  has  been  jiroved  by  numer- 
ous cases  from  acute  miliary  tubercle,  tuberculous  sputa,  and  the 
products  of  cheesy  metamorphoses  from  the  lungs  and  lymph-glands, 
and  granulations  from  scrofulous  inflammations  of  the  bones  and 
joints.  So  you  see  JRokitansky  was  correct  when,  in  his  fundamen- 
tal work,  he  described  yellow  tubercles,  cheesy  metamorphosis,  tu- 
berculous infiltration,  tuberculosis  of  the  bones  and  synovial  mem- 
branes, as  results  of  tuberculosis,  and  treated  scrofulous  inflammation 
of  the  lymphatic  glands  as  tuberculosis  of  these  organs. 

The  infectious  nature  of  tuberculosis  once  proved,  the  next  ques- 
tion was  as  to  the  nature  of  tuberculous  virus.  Hueter  and  Klehs 
had  already  advanced  the  view  that  it  was  a  fungus  ;  of  late,  cocci 
have  been  found  in  the  products,  "  monas  tuberculosum  "  has  been 
cultivated,  and  its  inoculation  is  said  to  induce  the  same  effects  as 
those  from  tuberculous  products.] 

If  from  what  has  just  been  said  we  recognize  to  the  full  extent 
the  immense  progress  recently  made  in  the  knowledge  of  tubercu- 
losis, still  we  must  not  fail  to  see  that  it  does  not  fully  explain  the 
interesting  connection  between  some  chronic  surgical  diseases  and 
tuberculosis  of  internal  organs,  especially  of  the  lungs.  Although 
there  are  a  good  many  cases  where  pulmonary  tubercles  follow 
chronic  suppuration  of  bones  or  joints,  and  caseous  degeneration  of 
swollen  lymphatic  glands,  just  as  often  death  of  the  patient  results, 
after  years  of  illness,  from  exhaustion,  and  on  section  we  do  not 
find  a  trace  of  tubercle.  Cinder  some  circumstances,  too,  there  is 
no  absorption  of  the  caseous  masses,  or  else,  if  absorbed,  they  do 
not  induce  tubercle.  This  would  go  to  prove  that  there  must  not 
only  be  a  disposition  of  inflammatory  foci  to  become  caseous,  but 
also  a  disposition  to  the  dissemination  of  tubercles,  and  that  these 
tM^o  dispositions  are  not  necessarily  combined  as  in  the  rabbit  and 
Guinea-pig.  The  fact  that  around  a  small  inoculation  a  cheesy 
focus  forms,  and  from  this  disease  is  disseminated  to  the  internal 
organs,  is  a  peculiarity  of  these  animals,  as  it  is  of  some  human 
beings.  This  peculiarity  is  called  the  tuberculous  diathesis.  Nor 
must  I  hide  from  you  that  some  pathologists  only  acknowledge  a 
frequent  coincidence  between  chronic  suppurating  or  caseous  foci 
and  tubercle,  and  refer  both  to  a  common  unknown  cause.  But  all 
this  cannot  prevent  me  from  recognizing  the  exceeding  value  of  the 
above-described  recent  observations,  and  regarding  them  as  one  of 
the  greatest  advances  of  modern  pathology. 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS.  467 

[Modern  views  of  tuberculosis  have  affected  the  treatment; 
firstly,  as  to  prophylaxis,  knowing  that  it  may  not  only  be  derived 
from  men,  but  also  from  beasts.  But  the  surgeon  is  esjjecially  in- 
terested in  the  extension  from  local  foci :  we  do  not  know  how  long 
it  may  require  for  a  general  infection  to  result  from  a  local  affec- 
tion ;  we  cannot  always  decide  whether  an  external  tuberculous 
focus  is  the  I'esult  of  a  primary  local  infection,  or  whether  there 
has  been  tuberculosis  in  some  other  part  of  the  body  that  has  es- 
caped our  observation.  Cohnheim  says  the  bronchial  and  tracheal 
lymphatic  glands  have  often  undergone  caseous  degeneration  when 
no  tubercles  can  be  found  in  the  lungs  ;  as  we  have  stated,  breathing 
is  the  commonest  mode  of  infection,  and  the  lymph-glands  are  the 
best  soil  for  developing  the  poison.  The  course  of  the  disease  varies 
greatly  in  man  ;  sometimes  the  general  infection  immediately  follows 
the  local,  again  years  intervene,  or  it  never  occurs.  The  local  pro- 
cess cicatrizes  or  calcifies,  and  the  tuberculous  virus  becomes  innocu- 
ous. Many  observations  prove  that  tuberculosis  is  inherited,  but 
we  do  not  know  how  the  semen  or  ova  can  carry  it ;  marriages 
should  be  avoided  among  those  who  are  tuberculous  or  come  from 
tuberculous  families.  From  the  great  frequency  of  tuberculosis, 
and  the  various  opportunities  for  its  inheritance,  transfer,  etc.,  why 
does  it  not  become  even  more  common  ?  Cohnheim  thinks  this  is 
because  our  generation  is  acquiring  a  certain  immunity  to  the  virus  ; 
he  thinks  this  immunity  will  also  explain  why,  in  some  patients, 
local  tuberculous  affections  do  not  become  general. 

Local  foci  may  sometimes  be  removed  by  a  sharp  scoop  or  by 
resecting  joints,  etc.,  and  general  infection  be  thus  prevented  in 
some  cases  ;  but  often  the  process  begins  again  near  the  site  of  the 
operation,  or  the  granulations  covering  the  wound  become  tuber- 
culous ;  cicatrization  may  still  go  on  but  within,  the  granulations, 
instead  of  changing  to  connective  tissue,  have  tubercles  disseminated 
through  them,  these  become  cheesy  and  suppurate.  The  common 
treatment  for  local  tubercle  has  been  removal  and  cauterization  of 
the  surrounding  parts  with  chloride  of  zinc  or  iron,  caustic  potash, 
etc.  Now  it  is  claimed  {3Iosetig-3Ioorhof)  that  iodoform  has  a 
decided  antituberculous  action.  The  wound  left  after  removing 
diseased  parts  should  be  filled  with  iodoform,  then  normal  granula- 
tions develop  which  change  to  firm  connective  tissue,  and  cure  re- 
mains perfect.  We  do  not  know  why  iodoform  acts  thus,  but  con- 
tinuous development  of  iodine  takes  place  on  the  surface  covered 
with  the  iodoform  ;  there  is  no  decomposition.  Under  this  applica- 
tion there  is  little  local  or  constitutional  reaction,  and  only  a  slight 
traumatic  fever  from   absorption  of    non-inflammatory  secretion. 


468  TUBERCULOSIS. 

The  nutrition  of  patients  treated  with  iodoform  almost  always  im- 
proves ;  they  look  well,  increase  in  weight,  but  in  rare  cases  it  has 
pi'oved  a  fatal  poison  ;  favorable  as  has  been  the  effect  on  the  local 
affections,  some  patients  go  on  to  die  of  the  general  disease.  Mole- 
schott  used  it  internally  against  tuberculosis,  and  even  claimed  that 
with  it  he  had  cured  tuberculous  meningitis. 

Prof.  H.  B.  Sands,  Nexo  York  3Tedical  Record,  May  25,  1882, 
gives  an  interesting  article  on  "  Iodoform,"  in  which  he  states  that 
he  has  seen  two  cases  of  acute  mania  due  to  poisoning  by  external 
use  of  this  drug.  The  symptoms  were  melancholy,  delirium,  dis- 
gust for  food,  emaciation,  profuse  sweating.  With  this  as  with  other 
substances,  fresh  wounds  absorb  more  rapidly  than  granulating  ones. 
The  proportion  of  cases  that  suffer  constitutional  effects  from  the 
local  application  of  the  remedy  must  be  very  small. 

Schilller's  experiments  led  him  to  believe  that  anti-bacterial 
remedies,  such  as  carbolic  acid  and  benzoate  of  soda,  had  a  directly 
curative  effect  on  tuberculosis,  but  this  has  not  been  proved. 

Hence,  the  first  efforts  of  treatment  should  be  to  increase  the 
resisting  powers  by  good  diet,  and  remove  any  disease  likely  to 
cause  tuberculosis  ;  in  the  case  of  limbs,  to  amputate  early  ;  in  case 
of  catarrhs,  to  cure  speedily.  In  some  cases  change  of  residence  to 
a  southern  clime  for  some  years  may  be  desirable.] 

The  new  etiology  of  tuberculosis  has  given  treatment  a  peculiar, 
and,  at  a  casual  glance,  a  changed  position.  We  now  have  to  ask 
ourselves  the  following  question :  Is  there  any  remedy  or  mode  of 
treatment  by  which  we  can  prevent  a  person,  who  has  on  or  in  him 
any  caseous  pus,  from  being  infected  with  tuberculosis  ?  To  this  we 
must  at  once  say  no.  The  mode  of  infection  is  so  little  known,  that 
on  this  account  alone  we  could  not  speak  of  its  prevention.  The  in- 
terval between  the  development  of  the  primary  point  of  inflammation 
and  the  succeeding  tuberculous  infection  is  entirely  incomputable. 
In  some  eases  the  formation  of  tubercles  in  the  lungs  appears  to  fol- 
low almost  on  the  heels  of  chronic  bronchial  catarrh,  while  in  other 
cases  the  two  forms  of  disease  are  separated  by  years.  Typical  tuber- 
cles may  also  dry  up  and  become  indurated  in  various  ways,  or  they 
may  rapidly  increase,  unite,  and  soften.  In  short,  the  variety  of  the 
process  is  very  great.  But  all  this  gives  no  starting-point  for  the 
treatment.  As  regards  hereditary  influence,  to  Avhich  so  much  im- 
portance is  properly  attached  in  tuberculosis,  some  enigmas  have  been 
solved  by,  and  some  former  experiences  readily  adapt  themselves  to, 
the  new  views.  If  true  tubercle  could  onl}'-  develop  from  infection 
through  the  patient  himself,  of  course  there  could  be  no  talk  of  direct 
inheritance  of  tuberculosis  in  the  strict  meanina:  of  the  term.     Onlv 


GOUT.  469 

the  tendency  to  chronic  inflammations,  ending  in  suppuration  and 
caseous  degeneration,  is  hereditary  ;  in  other  words,  the  scrofulous 
diathesis,  not  the  tuberculous,  is  hereditary.  We  must  bear  this  in 
inind  ;  the  experience  of  family  physicians  agrees  with  it  entirely  ; 
but  we  must  understand  that  such  general  rules  are  only  true  in 
theory.  The  hereditary  tendency  to  diseases  of  certain  organs,  and 
to  certain  forms  of  disease,  is  such  a  complicated  question  that  we 
should  be  very  reserved  in  stating  general  laws  about  it.  Apart 
from  the  occasional  accidental  complications,  such  as  meningitis, 
haemorrhages,  pneumothorax,  empyema,  peritonitis  from  perforation 
of  intestines,  pyoemia,  etc.,  tuberculosis  may  prove  fatal  by  extensive 
suppuration  and  the  rapid  febrile  marasmus,  or  by  amyloid  degener- 
ation of  internal  organs  due  to  the  suppuration,  or,  lastly,  by  acute 
miliary  tuberculosis,  i.  e.,  by  an  extensive  eruption  of  tubercles  in 
internal  organs,  accompanied  by  general  poisoning,  where  the  pa- 
tient is  in  a  typhoid  state.  In  the  earlier  stages  recovery  may  take 
place,  but  leaving  a  tendency  to  relapse. 

If  we  put  together  what  may  be  said  about  the  indications  for 
treatment  of  tuberculosis,  it  would  be  about  as  follows :  We  cannot 
prevent  either  the  development  or  progress  of  tubercles.  Hopeless 
as  this  sounds,  it  remains  to  be  added  that  medical  care  may  acccm- 
plish  something  in  hindering  the  development  of  those  processes 
which  are  so  often  followed  by  tuberculosis.  The  early,  careful, 
general  dietetic  and  local  treatment  of  chronic  diseases  of  the  bones 
and  joints,  and  even  tlie  amputation  of  limbs,  or  the  resection  of 
bones  at  the  proper  time,  may  prevent  the  development  of  tubercle. 
In  the  same  way,  great  care  of  catarrhs  of  all  sorts,  and  their  most 
perfect  removal,  is  undoubtedly  the  most  effectual  thing  we  can  do 
to  remove  the  tuberculous  infection.  In  tuberculosis  the  treatment 
is  the  same.  All  the  remedies,  baths,  and  places  for  treatment,  that 
are  prescribed,  have  for  their  object — 1,  to  remove  or  diminish  the 
existing  catarrh  or  other  primary  disease  ;  2,  to  improve  the  nutri- 
tion of  the  patients,  wlio  are  generally  emaciated  ;  3,  to  avoid  every 
thing  that  can  render  the  patients  feverish.  T  must  leave  it  for  the 
lecturer  on  clinical  medicine  to  make  you  better  acquainted  with 
the  important  principles  of  treatment  in  this  frequent  and  fearful 
disease. 

3.  Arthritis,  or  go^(t,  is  a  tendency  to  disease  which  usually  ap- 
pears first  about  the  thirtieth  to  the  forty-fifth  year  of  life  and  later  ; 
it  is  often  confounded  with  chronic  rheumatism,  but  really  differs 
from  it  considerably.  True  gout  is  a  rare  disease  with  us,  and  is  dis- 
tinguished from  rheumatism  by  the  fact  that  it  occurs  in  attacks, 
often  recurs  only  once  a  year,  or  at  stated  intervals,  while  meantime 


470  CHRONIC   INFLAMMATIOX   OF   THE   SOFT   PARTS. 

the  individual  remains  perfectly  well.  Gout  is  a  disease  of  tlie  rich, 
and,  as  old  physicians  who  had  it  themselves  used  to  say,  of  wise  men. 
It  occurs  chiefly  in  men  who  lead  a  comfortable,  inactive  life;  it  not 
unfrequently  descends  to  the  next  generation,  but  always  appears 
first  after  middle  age.  Harvey,  Sydenham,  and  many  other  cele- 
brated physicians,  suffered  from  gout.  The  inflammations  occurring 
in  gout  are  chiefly  limited  to  certain  joints,  and  the  parts  around 
them.  The  joint  between  the  metatarsus  and  the  first  phalanx  of  the 
big  toe  is  affected  particularly  often  ;  this  is  the  seat  of  true  podagra. 
The  wrist  and  the  joints  of  the  phalanges  may  also  be  attacked  by 
gout ;  here  it  is  called  chiragra.  The  skin  over  the  joint  is  impli- 
cated in  these  inflammations.  During  the  attack  it  becomes  bright 
red  and  very  sensitive,  as  in  erysipelas  ;  and,  in  rare  cases,  ulcers 
may  form  during  this  process.  Arterial  thickenings  (atheroma  of  the 
artery),  with  their  occasional  results,  cerebral  apoplexy  and  senile 
gangrene,  are  not  unfrequent  in  arthritic  patients.  Corpulence,  dis- 
eases of  the  liver  and  kidneys,  may  also  accompany  gout;  gravel, 
especially  a  fine  granular  excretion  of  uric  or  oxalic  acid  from  the 
kidneys  into  the  bladder,  is  not  unfrequent,  but,  just  as  frequently, 
large  renal  and  vesical  calculi  develop.  In  the  diseased  joints  and 
sheaths  of  the  tendons  considerable  quantities  of  urates  have  been 
seen,  occasionally  in  such  quantities  that  they  covered  the  articular 
surfaces  and  capsule  like  a  white  graniilar  coating.  Kx\  attack  of 
gout  is  usually  preceded  for  some  time  by  a  general  feeling  of  being 
out  of  sorts,  which  disappears  as  soon  as  the  inflammation  attacks 
some  external  point,  usually  a  joint.  These  inflammations  last  two 
or  three  weeks,  and  then  subside,  often  leaving  permanent  thickening 
of  the  joint ;  but  in  other  cases  the  diseased  limbs  often  remain  un- 
changed for  years.  In  some  old  arthritic  patients  these  stone-like 
gout-nodules  are  also  found  in  the  skin,  as  in  that  of  the  ear,  as  well 
as  in  the  joints  and  sheaths  of  the  tendons.  If  these  nodules  break 
off,  the  masses  of  lime  and  urates  may  be  scooped  out  with  an  ear- 
spoon  ;  the  complete  suppuration  and  closure  of  these  open  and 
very  painful  gouty  nodules  then  last  for  months.  Operations  with 
the  knife  in  such  cases  should  be  carefully  avoided.  The  ordinary 
attack  of  podagra  never  ends  in  suppuration,  always  in  resolution. 
From  this  etiological  relation  of  the  abnormal  deposits  of  uric  acid 
to  the  joint  affection,  gout  has  also  been  called  arthritis  urica. 

The  treatment  of  the  attack  of  gout,  of  the  gouty  articular  in- 
flammation, is  to  be  distinguished  from  the  general  treatment.  The 
former  almost  always  runs  a  typical  course,  which  is  not  materially 
changed  by  treatment.  The  first  indication  for  medical  aid  is  to  al- 
leviate the  pain  by  moderating  the  inflammation ;  for  this  purpose 


SYPHILIS.  471 

ice  might  answer  very  well,  if  there  were  not  certain  reasons  for 
fearing  its  effects,  for,  from  the  frequent  presence  of  atheroma  of  the 
smaller  arteries,  great  cold  might  induce  gangrene.  There  is  not 
much  to  be  said  against  the  application  of  cold  compresses,  cold  fo- 
mentations with  lead-water,  weak  solutions  of  nitrate  of  silver,  or 
local  applications  of  leeches ;  but  many  gouty  patients  prefer  greas- 
ing the  joint  and  wrapping  it  in  wadding.  Profuse  diaphoresis,  in- 
duced by  hot  tea  and  hydropathic  packing,  is  said  to  shorten  the 
attacks.  In  the  constitutional  treatment  of  the  arthritic  diathesis, 
mineral  waters  take  the  first  rank.  Gouty  patients  should  be  ad- 
vised to  use  the  waters  of  Karlsbad,  Kissingen,  Homburg,  Vichy, 
and  other  saline  springs,  also  the  thermal  waters  of  Teplitz,  Gastein, 
Wiesbaden,  and  Aix-la-Chapelle.  But  Ave  may  expect  an  acute 
attack  of  gout  to  follow  the  use  of  warm  baths. 

4.  The  scorbutic  dysc7'asia  manifests  itself  in  great  fragility  of 
the  capillary  vessels,  and  consequent  subcutaneous  htemorrhages, 
which  result  from  ruptures  of  the  vessels  or  from  diapedesis,  and 
may  be  induced  in  frogs  by  poisoning  them  with  ordinary  salt.  This 
disease  is  supposed  to  be  due  to  dissolution  of  the  blood,  without 
any  accurate  description  being  given  of  the  blood-change  causing 
the  change  in  the  vessels.  The  disease  is  almost  entirely  endemic, 
for  instance,  on  the  shores  of  the  Baltic,  and,  in  a  surgical  point  of 
view,  is  not  very  interesting.  When  treating  of  ulcers  in  the  next 
chapter,  we  shall  refer  to  it  again. 

5.  The  syphilitic  dyscrasia.  Although  I  do  not  propose  to  in- 
clude syphilis  in  the  subjects  of  these  lectures,  still,  for  the  sake  of 
completeness,  I  must  make  some  remarks  on  it.  This,  like  the  above 
diathesis,  developed  in  man  at  some  time,  but  now  it  is  spread  entire- 
ly by  inoculation.  The  person  inoculated  is  syphilitic  from  the  mo- 
ment the  virus  takes  effect.  In  speaking  of  syphilitic  diseases  in 
general  terms,  three  different  diseases  are  included :  (1)  gonorrhcea, 
a  blennorrbaa  of  the  vagina,  then  of  the  urethra,  which  thence  oc- 
casionally extends  to  the  excretory  ducts  of  the  testicles  and  pros- 
tate, and  may  induce  gonorrhoeal  prostatitis  or  orchitis  ;  prolifera- 
tions of  the  papillary  bodies,  in  form  of  the  so-called  condylomata 
(from  iiov6vXo(;,  a  button-like  prominence  on  bone),  often  occur  where 
gonorrhoeal  pus  stagnates  ;  (2)  the  soft  chancre,  an  ulcer,  usually  on 
the  glans  and  prepuce,  w'hich  frequentl}-,  through  the  lymphatic  ves- 
sels, excites  an  inflammation  of  the  inguinal  glands,  which  has  a  great 
tendency  to  go  on  to  suppuration  ;  (3)  the  proper  syphilitic  ulcer, 
the  hidurated  chancre.  In  this  the  general  disease  occurs  at  the 
time  of  inoculation,  while  the  first  and  second  form  remain  relatively 
local.     In  inoculation  w'ith  the  secretion  of  a  true  syphilitic  ulcer, 


472  CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS. 

the  entire  organism  is  infected  at  once  ;  a  series  of  chronic  inflamma- 
tions occur  in  the  most  varied  organs,  which  have  at  first  a  more  pro- 
ductive character,  but  soon  lead  to  disintegration  of  the  infiltrated 
tissue  and  assume  an  ulcerative  destructive  character.  The  following 
symptoms  may  appear  in  syphilis :  eruptions  on  the  skin  of  blotches, 
papules,  desquamations,  and  nodules ;  ulcers  in  the  fauces,  on  the  lips 
and  tongue,  and  about  the  anus  ;  osteoplastic  and  ulcerative  periosti- 
tis and  ostitis,  especially  on  the  til)ia,  cranial  bones,  sternum,  etc.  ; 
chronic  inflammations  of  the  greatest  variety,  usually  with  caseous 
degeneration  in  the  testicles,  liver,  brain,  and  possibly  in  the  lungs. 
The  nodular  circumscribed  product  of  syphilis  is  called  by  Virchow 
"  gummy  tumor,"  by  ^.  Wagner  "  syphiloma."  Syphilis  may  also 
be  inherited  ;  children  are  born  with  it  ;  the  dyscrasia  may  be  car- 
ried by  the  sperm  to  the  ovum,  or  be  in  the  ovum.  It  is  still  dis- 
puted whether  a  healthy  woman  who  has  been  imj^regnated  by  a 
healthy  man,  and  has  become  syphilitic  during  pregnancy,  can  con- 
vey the  disease  to  the  foetus,  and  whether  a  foetus  begotten  by  a 
syphilitic  man  who  has  no  ulcer  on  the  penis  can  infect  the  healthy 
mother.  It  is  also  disputed  by  some  that  the  venereal  poison  can 
pass  through  the  placenta. 

Gonorrhciea  and  the  soft  chancre  are  local  diseases,  and  are  to  be 
treated  as  such.  Formerly  soft  and  indurated  chancres  were  regarded 
as  two  forms  of  syphilis,  with  many  connecting  links  ;  of  late  the 
dualistic  theory  seems  to  gain  more  and  more  suppoi'ters,  although 
there  is  still  much  discussion  on  the  subject.  Many  surgeons  con- 
sider mercury  as  a  specific,  or  as  a  sort  of  antidote,  in  syphilitic  dys- 
crasia. It  seems  to  me  proved  by  recent  observations  that  this  is  not 
exactly  true.  Constitutional  syphilis,  which  only  attacks  a  person 
once,  may  in  the  course  of  time  be  to  some  extent  gotten  rid  of  by 
the  change  of  tissue  ;  hence  all  remedies  that  greatly  promote  the 
change  of  tissue  are  in  a  certain  sense  antisyphilitic.  Most  frequent- 
ly treatment  by  sweating  or  purging  is  resorted  to  ;  occasionally 
syphilis  is  cured  by  a  treatment  of  six  weeks  ;  in  some  cases  these 
modes  of  treatment  must  be  continued  with  interruptions  till  they 
prove  successful,  and,  finally,  some  cases  are  entirely  incurable.  Oc- 
casionally mercury,  by  inunction  or  internally,  in  various  preparations, 
continued  a  long  time,  removes  the  symptoms  of  syphilis  with  sur- 
prising rapidity ;  and  hence,  in  cases  where  we  desire  to  arrest  as 
quickly  as  possible  certain  ulcerative  forms,  especially  in  the  bones, 
it  will  maintain  its  value.  Of  late  it  has  been  much  doubted  if  mer- 
cury alone  can  cure  syphilis,  and  at  the  same  time  it  has  been  shown 
what  injury  may  be  induced  by  continued  use  of  mercurials,  by  a  sort 
of  chronic  mercurial  poisoning  (hydrargyrosis).     The  mercurialists 


SYPHILIS.  473 

and  anti-mercurialists  have  disputed  for  a  long  time  ;  and  in  the 
last  decennium  it  has  entered  new  stages,  without,  however,  having 
brought  all  physicians  to  a  conclusion  on  this  question.  I  incline  to 
the  views  of  the  anti-mercurialists.  In  the  course  of  your  studies 
you  will  hear  still  more  about  this  important  and  interesting  point. 
Iodide  of  potash"  is  generally  recognized  as  one  of  the  most  impor- 
tant and  efficacious  remedies  for  syphilitic  diseases  of  the  bones  and 
glands,  while  it  does  little  good  in  other  syphilitic  diseases. 

[Rapid  cures  of  syphilis  are  rare  ;  and  many  patients,  apparently 
cured,  in  after-years  have  syphilitic  eruptions  or  severe  forms  of 
syphilis  of  the  brain  or  other  internal  organs.  Hence,  we  should 
guard  against  being  deceived  by  the  apparent  effect  of  a  short 
treatment  ;  but  with  proper  changes  this  should  continue  two  or 
three  years. 

Of  late  it  is  claimed  that  in  the  secretions  from  gonorrhoea, 
chancroids,  and  chancres,  micrococci  characteristic  of  the  different 
diseases  have  been  found,  but  this  lacks  confirmation.] 


474  LOCAL  TREATMENT  OF  CHRONIC  INFLAMMATION 


LECTURE    XXX. 

Local  Treatment  of  Chronic  Inflammation:  Rest,  Compression,  Resorbents,  Atitlplilo- 
gistics,  Derivatives,  Fontanels,  Setous,  Moxsb,  the  Hot  Iron. 

It  still  remains,  at  the  close  of  the  chapter  on  chronic  inflamma- 
tion, to  run  through  the  remedies  that  we  may  employ  locall}',  and 
which  are  more  or  less  prominent  according  to  the  case.  Where  we 
do  not  succeed  in  finding  a  constitutional  cause  for  a  chronic  inflam- 
mation, we  are  limited  to  local  remedies. 

Absoh/te  rest  of  the  inflamed  part  is  necessary  in  all  cases  where 
there  are  pain  and  congestion.  When  possible,  these  are  combined 
with  elevation  of  the  diseased  part,  by  means  of  suspensories  or  pads 
placed  beneath.  This,  by  facilitating  the  return  of  the  blood,  has 
the  effect  of  relieving  and  finally  removing  the  venous  tension,  which 
is  favored  by  the  absolute  rest,  and  hence  is  especially  important  in 
cases  where  venous  congestion  has  induced  or  increased  chronic 
inflammation. 

Compression.  This  is  applied  by  wrapping  the  diseased  part 
with  moist  or  elastic  bandages,  plaster-dressing,  strips  of  adhesive 
plaster,  or  even  by  covering  with  moderate  weights  (us  in  compressing 
swollen  inguinal  glands).  Compression  is  one  of  the  most  important, 
and,  when  made  to  act  regularly,  is  the  most  certain  means  of  re- 
moving chronic  inflammatory  infiltrations. 

Massage,  of  which  we  spoke  when  treating  of  distortions,  is  par- 
ticularly serviceable  for  getting  rid  of  old  infiltrations;  it  sometimes 
accomplishes  wonders  ;  but  this  method  of  treatment  must  be  fol- 
lowed with  great  energy  and  perseverance. 

3Ioist  loarmth  in  the  form  of  cataplasms,  continually  applied,  is 
also  very  efficacious,  as  are  also  the  hydropathic  icraps.  These  are 
applied  by  dipping  a  cloth,  folded  several  times,  in  cold  water,  wring- 
ing it  out,  enveloping  the  affected  part  with  it,  and  covering  with 
some  air-tight  substance,  such  as  oil-silk,  gutta-percha  cloth,  etc.,  and 


CHRONIC   INFLAMMATIOX   OF  THE   SOFT   PARTS.  475 

renewing  this  dressing  every  two  or  three  hours.  The  skin,  at  first 
much  cooled,  soon  becomes  very  warm  ;  then  the  dressing  should  be 
renewed,  so  that  the  cutaneous  vessels  are  kept  active  by  the  change 
from  cold  to  warm,  and  are  thus  placed  in  the  bast  state  for  absorb- 
ing.    In  some  cases  these  wraps  are  very  useful. 

Resolvent  remedies.  Fomentations  with  lead-water,  infusion  of 
arnica,  camornile-tea,  etc.,  have  some  reputation  as  resolvent  appli- 
cations, which  they  do  not,  however,  deserve  ;  they  rather  belong  to 
the  category  of  inactive  domestic  remedies.  Mercurial  salve,  mercu- 
rial plaster,  ointment  of  iodide  of  potassium,  and  tincture  of  iodine, 
are  also  absorbents  which  may  be  employed  alternately  in  chronic 
inflammations.  I  am  far  from  denying  them  any  efficacy  in  such 
cases;  but  you  must  not  expect  too  much  from  them.  Of  late, 
tincture  of  iodine,  in  doses  of  5-10  drops,  has  been  injected  into 
lymphatic  glands,  but  with  very  uneven  effect.  I  pass  over  a  series 
of  resolvent  plasters  ;  they  do  little  good  in  this  way  ;  their  effect  is 
partly  as  slight  irritants  to  the  skin,  partly  as  protective  coverings ; 
in  some  cases  I  order  such  plasters  to  prevent  the  patient  from  ap- 
plying something  injurious ;  mercurial  plaster  only  has  a  medicinal 
effect  when  used  for  a  long  time.  I  may  mention  electricity  as  a 
discutient  remedy  ;  its  effect  does  not  seem  to  be  very  great,  but 
cases  are  reported  where  it  has  been  used  with  advantage  ;  further 
investigations  should  be  made  on  this  point. 

Antiphlogistic  remedies  proper,  such  as  ice,  leeches,  cups,  etc., 
about  which  you  will  learn  in  the  clinic,  are  rarely  used,  and  are  only 
of  slight  temporary  benefit  in  chronic  insidious  inflammations ;  but, 
in  intercurrent  acute  attacks,  they  are  just  as  useful  as  in  primarily- 
acute  inflammations.  Some  surgeons  of  the  present  time,  especially 
Von  Esmarch.,  use  ice  continuously  in  chronic  torpid  inflammations, 
and  praise  the  result  of  this  treatment. 

De^'ii'atives.  These  play  an  extensive  role  in  the  treatment  of 
chronic  inflammations.  They  are  so  named  because  they  are  said  to 
remove  the  inflammation  from  its  location  to  other  points  where  it  will 
be  less  dangerous;  there  are  remedies  by  which  we  may  induce  cutane- 
ous inflammations  of  varied  grades,  and  which  have  been  proved  by 
careful  observers  to  have  an  excellent  curative  effect.  The  physio- 
logical explanation  of  the  mode  of  action  of  these  derivatives  is  as 
yet  an  unsolved  problem.  It  is  supposed  that,  from  the  application 
of  these  remedies  near  a  point  of  chronic  inflammation  in  a  bone  or 
joint,  the  blood  and  fluids  are  drawn  outward  to  the  skin.  In  some 
cases  of  inflammation  accompanied  by  little  energy  or  vascularization, 
the  derivatives  certainly  have  rather  an  opposite  effect  ;  i.  e.,  the  new 
acute  inflammation  induced  in  the  immediate  vicinity  of  the  chronic  one 


476  LOCAL   TREATMENT   OF   CHRONIC   INFLAMMATION. 

causes  stronger  fluxion  to  these  parts,  and  aro vises  the  chronic,  torpid 
inflammation  into  an  energetic,  active  state.  But  we  shall  not  worry 
ourselves  trying  to  discover  the  phj^siological  way  in  which  these 
remedies  act ;  this  has  always  been  a  very  thankless  task.  The  fol- 
lovvino'  remedies  of  this  class  are  practically  useful :  Nitrate  of  silver 
in  concentrated  solutions  mixed  with  fat,  and  rubbed  on  the  skin  a 
couple  of  times  daily,  induces  a  dark-brown  hue,  with  silvery  lustre 
in  the  skin,  and  a  slow  detach  n:ent  of  epidermis.  It  is  one  of  the 
mildest  derivatives,  and  is  particularly  suited  to  the  joint  diseases  of 
sensitive  children.  Tincture  of  iodine^  especially  the  strong  tincture 
(iodine  3  j  to  absolute  alcohol  |  j  dissolved  with  ether),  if  applied  to 
the  skin  morning  and  evening,  induces  a  tolerably  sharp  biu-ning 
pain ;  if  this  painting  be  continued  two  or  three  days,  the  epidermis 
is  elevated  into  a  vesicle,  occasionally  all  over  the  space  where  the 
remedy  has  been  applied.  Jilistering  plasters  act  more  raj^idly ;  they 
consist  of  powdered  cantharides  (lytta  vesicatoria,  meloe  vesicatorius) 
rubbed  up  with  wax  or  fat,  and  spread  on  linen,  leather,  or  oiled  mus- 
lin. Well-made  ordinary'  emplastrum  cantharidum,  in  pieces  as  large 
as  a  franc  or  a  dollar,  is  fastened  on  the  skin,  and  in  twenty-four  hours 
a  vesicle  forms  under  it ;  this  is  to  be  punctured,  and  a  piece  of  wad- 
ding applied  over  it ;  this  dries  on  and  becomes  detached  in  three  or 
four  days,  at  which  time  the  detached  hard  layer  of  the  epidermis  has 
been  regenerated  from  the  rete  Malpighii.  A  large  spanish-flj'^  blister 
may  be  applied  once,  or  a  small  one  may  be  applied  new  every  day ;  the 
latter  method  is  called  vesicatoires  volantes.  Lastly,  we  may  apply 
plasters  containing  only  a  small  amount  of  cantharides,  and  only  in- 
ducing continued  redness.  This  is  the  emplastrum  cantharidum  per- 
petuum,  or  emplastrum  euphorbii ;  it  is  worn  several  days  or  weeks  in 
succession.  Although  the  favorable  action  of  the  above  derivative 
remedies  in  chronic  inflammation  cannot  be  denied,  I  may  say  that 
particularly  tincture  of  iodine  and  blisters  do  much  more  good  in  sub- 
acute inflammations,  or  the  slight  intercurrent  acute  attacks  in  chronic 
inflammation,  than  in  the  painless  torpid  forms. 

The  remedies  still  left  to  mention  are  those  followed  by  long-con- 
tinued suppuration,  a  suppuration  which  is  kept  up  by  artificial  ex- 
ternal irritation,  according  to  the  wiU  of  the  physician.  Their  use  is 
so  diminished  during  the  last  ten  years  that  at  present  very  few  sur- 
geons resort  to  them. 

Tartar-emetic  ointment  and  croton-oil.  When  rei)eatedly  apphed 
to  the  skin  for  a  length  of  time,  in  about  six  or  eight  days,  or  in  irrit- 
able skins  earlier,  both  of  these  induce  a  pustular  eruption,  which  is 
not  unfrequently  painful.  When  these  pustules  begin  to  show  them- 
selves, we  stop  the  applications  and  allow  the  pustules  to  heal.     Con- 


CHRONIC   INFLAMMATION   OF   THE   SOFT   PARTS.  477 

siderable  cicatrices  not  unfrequently  remain  ;  the  effect  of  these  rem- 
edies is  I'ather  uncertain,  so  that  they  are  not  often  used. 

By  fonticulus  or  a  fontanel  (from  fons,  well),  we  mean  an  inten- 
tionally-induced wound  of  the  skin  that  is  kept  suppurating;  it 
may  be  induced  in  various  ways.  You  may  apj^ly  an  ordinary  blister- 
plaster,  then  cut  the  blister  and  daily  dress  the  part  denuded  of  epi- 
dermis with  ointment  of  cantharides  or  other  irritating:  salve.  You 
will  thus  induce  a  suppuration  that  you  may  keep  up  as  long  as  you 
continue  this  mode  of  dressing.  Another  way  of  making  a  fontanel 
is  to  incise  the  skin  and  place  a  number  of  peas  in  this  incision,  re- 
taining them  in  position  by  adhesive  plaster.  The  peas  swell  up,  and 
are  to  be  daily  renewed ;  they  irritate  the  wound  as  foreign  bodies ;  a 
simple  ulcer  is  thus  artificially  induced.  It  is  always  simplest  to 
make  the  fontanel  with  an  incision,  but  we  may  bxirn  the  skin  thor- 
oughly with  any  caustic,  and  keep  the  resulting  wound  suppurating 
by  the  introduction  of  peas. 

The  set07i  is  a  small  strip  of  linen,  or  an  ordinary  lamp-wick,  which 
is  drawn  under  the  skin  by  means  of  a  peculiar  needle.  The  seton- 
needle  is  a  moderately-broad,  rather  long  lancet  with  a  large  eye  at 
its  lower  end,  to  carry  the  seton.  Setons  are  generally  appHed  to  the 
back  of  the  neck  in  the  following  manner  :  with  the  thumb  and  fore- 
finger of  the  left  hand  you  lift  as  large  a  fold  of  skin  as  possible,  trans- 
fix it  at  its  base  with  the  threaded  seton-needle  and  draw  the  latter 
through.  After  the  seton  has  lain  quiet  a  few  days,  and  suppuration 
begins,  pvill  it  forward  and  cut  off  the  part  impregnated  with  pus;  re- 
peat this  daily.  Granulations  form  in  the  whole  canal  occupied  by 
the  seton  ;  these  secrete  quantities  of  pus.  The  seton  is  worn  for 
weeks  or  months,  and  removed  when  we  wish  the  suppuration  to 
cease. 

Another  mode  of  inducing  continued  suppuration  is  by  making  a 
slough  in  the  skin  b}'  means  of  heat  and  preventing  the  resulting  granu- 
lating wound  from  healing  by  irritating  dressings  or  by  introducing 
peas ;  this  may  be  kept  up  a  longer  or  shorter  time,  according  to  the 
effect  desired.  For  this  purpose  there  are  two  modes  of  operation,  by 
the  so-called  moxa  and  by  the  hot  iron.  Mox£e  are  thus  prepared :  a 
wad  of  cotton  is  tied  together  with  silk  thread,  then  soaked  in  spirits, 
held  on  the  skin  w4th  forceps  and  there  burned.  Various  grades  of 
burn  may  be  induced  by  the  longer  or  shorter  action.  There  are  other 
modes  of  preparing  moxae,  which,  however,  I  shall  not  here  describe, 
as  moxae  are  now  little  used.  If  you  Avish  to  induce  a  slough  in  the 
skin,  it  may  be  most  simjily  done  by  strong  caustics  and  caustic 
pastes,  or  by  the  hot  iron.  The  cautery-irons  used  in  surgery,  already 
mentioned  among  the  hemostatic  remedies,  are  thin  iron   rods  a  foot 


478  LOCAL   TREATMENT   OF   CHRONIC   INFLAMMATION. 

long,  with  Avooden  bandies,  and  with  a  button-shaped,  cylindrical,  or 
prismatic  end,  which  is  placed  in  a  basin  of  hot  coals  till  it  reaches 
a  red  or  white  heat.  With  this,  various  grades  of  burns,  even  to 
charring  the  skin,  and  burns  of  variable  size,  form,  and  depth,  may  be 
induced,  according  as  we  desu'e  extensive  sujDpuration,  or  several  dis- 
tinct small  ulcers. 

It  would  lead  me  too  far,  and  not  be  very  comprehensible  for  you 
at  present,  were  I  here  to  enter  into  an  exhaustive  criticism  about  the 
choice  and  various  gradations  of  the  above  remedies.  These  are 
things  that  you  learn  more  quickly  and  certainly  in  the  clinic,  from  the 
remarks  on  an  individual  case.  I  will  only  observe  that  the  appHca- 
tion  of  the  more  intense  derivatives,  such  as  fontanels,  moxas,  setons, 
and  the  hot  iron,  to  children  and  suscejDtible,  delicate  persons,  should 
be  made  very  carefully,  and  had  better  be  avoided.  I  scarcely  ever 
use  the  hot  iron  as  a  derivative,  though  I  sometimes  employ  it  to 
destroy  spongy  granulations  in  caries,  occasionally  with  very  good 
effect. 

Almost  all  classes  of  remedies  have  for  a  time  been  somewhat  the 
fashion,  according  to  the  prevailing  theories,  and  so  there  was  a  time 
Avhen  raoxfe,  the  hot  iron,  or  fontanels,  were  praised  as  universal  rem- 
edies in  every  chronic  inflammation.  A  fontanel  was  applied  on  the 
arm  to  protect  the  person  against  rheumatism,  haemorrhoids,  tubercu- 
losis, or  cancer,  with  the  idea  that  with  the  pus  from  the  fontanel  all 
morbid  juices,  the  materia  peccans,  were  thrown  off  from  the  body. 
In  the  same  way,  formerly,  at  certain  seasons,  purgatives,  emetics, 
venesections,  etc.,  were  resorted  to  yearly.  Even  at  present  you  will 
hear  old  practitioners  tell  gleefully  how  this  or  that  patient  was  pre- 
served from  a  multitude  of  ills  by  the  application  of  a  fontanel.  I 
shall  not  presume  to  criticise  what  may  be  accomplished  by  this  treat- 
ment, for,  as  was  mentioned,  Ave  are  far  from  knowing  how  to  meas- 
use  its  physiological  effect ;  but  Ave  should  mistrust  the  action  of  reme- 
dies that  are  recommended  against  all  possible  diseases. 

[We  may  apply  a  rubber  bandage,  or  (especially  for  swollen 
joints)  a  moistened  compx'essed  sponge  kept  in  place  by  bandage. 
The  compression  may  even  be  apjDlied  by  EsmarclCs  bandage  for  a 
short  time. 

Massage,  of  which  we  spoke  when  treating  of  sprains,  is  partic- 
ularly applicable  for  getting  rid  of  old  infiltrations  ;  it  sometimes 
induces  speedy  suppuration,  and  the  case  goes  on  as  one  of  acute 
abscess,  or  the  chronic  inflammatory  products  are  rendered  fluid 
and  absorbed  by  the  excited  blood  and  lymph  circulation.  Under 
it,  thickenings  dependent  on  true  iraflammatory  neoplasia  may  dis- 
appear rapidly  ;  even  coagulated  fibrine,  such  as  we  sometimes  find 


CHROXIC   INFLAMMATION   OF   THE   SOFT   PARTS.  479 

in  chronic  inflammations  of  the  nerve-sheaths,  may  be  reabsorbed. 
Besides  its  local  effect,  massage  may  stimulate  the  kidneys  to  in- 
creased secretion,  and  thus  cause  absorption  of  oedema  even  when 
its  local  cause  cannot  be  cured.] 

The  rapid  absorption  of  old  torpid  infiltrations  is  sometimes  very 
favorably  affected,  as  are  neuralgic  pains  in  chronically-inflamed 
parts,  by  warm  or  hot  local  niicd-baths.  In  some  parts  of  Hungary 
hot  springs  open  into  the  mud  of  small  streams  ;  in  this  natural  hot 
mud,  which  is  used  in  tubs,  the  diseased  limbs  are  soaked  once  or 
twice  daily  ;  similar  baths  are  prej^ared  artificially.  The  bog-baths 
at  Franzenbad  and  Marienbad  are  about  as  efficacious  ;  the  bog, 
soaked  with  ferruginous  water,  is  warmed  and  used  as  the  mud-baths 
above  described.  We  do  not  know  whether  the  mineral  salts  con- 
tained in  the  bath  have  any  effect  ;  they  j^robably  act  only  as  large 
cataplasms.  Compresses  wet  with  thermal  water  of  iodine-springs 
have  also  a  good  reputation  as  resorbents.  Usually  they  soon  in- 
duce cutaneous  eruptions,  and  may  also  be  considered  as  derivative 
remedies.  Animal-baths  are  also  very  popular ;  in  these  the  dis- 
eased limb  is  placed  among  the  intestines  of  an  animal  just  killed, 
and  kept  there  till  the  dead  body  is  cold  ;  a  peculiar  effect  is 
claimed  for  the  animal  warmth,  of  which  I  have  been  unable  to 
convince  myself.  Lastly,  we  must  mention  hot  sand-baths,  which 
were  formerly  very  popular  ;  these  probably  have  no  advantage 
over  moist  warmth. 


CHAPTER   XV 
ULCERS. 

LECTURE     XXXI. 

Anatomy. — External  Peculiarities  of  Ulcers  ;  Form  and  Extent,  Base  and  Seoret!a!i, 
Edges,  Parts  around. — Local  Treatment  according  to  the  Local  Condition  of  the 
Ulcer  •,  Fungous,  Callous,  Putrid,  Phagedenic,  Sinuous  Ulcers,  Etiology,  Contin- 
ued Irritation,  Venous  Congestion,  Dyscrasial  Causes. 

The  study  of  ulcers  naturally  follows  that  of  the  chronic  inflam- 
mations. Physicians  practically  agree  as  to  what  an  ulcer  is,  and 
whether  any  given  wounded  surface  is  to  be  so  regarded  ;  but,  to  give 
a  short  definition  of  it  is  about  as  difficult  as  it  is  to  define  any  other 
object  in  medicine  or  natural  history.  To  give  you  a  proximate  de- 
scription of  it,  we  may  say,  an  ulcer  is  a  wounded  surface  which 
shows  no  tendency  to  heal.  Here  you  see  at  once,  that  every  large 
granulating  wound  Mnth  free  proliferations,  which  halts  in  its  progress 
toward  cm-e,  may  also  be  regarded  as  an  ulcer,  and,  in  fact.  Mush,  to 
whom  we  owe  our  most  comprehensive  nomenclature  of  ulcers,  desig- 
nates granulatmg  wounds  as  ulcus  simplex. 

From  personal  observations  and  examinations  we  conclude  that 
ulceration  mostly  starts  from  chronic  inflammation,  and  is  always  pre- 
ceded by  cellular  infiltration  of  the  tissue. 

This  inflammation  may  be  located  in  the  depth  of  the  cutis,  in 
the  cellular  tissue,  muscles,  glands,  periosteum,  or  bones ;  in  the 
centre  of  the  inflamed  spot  there  is  suppuration,  caseous  degenera- 
tion, or  some  other  form  of  softening  and  breaking  down,  with  grad- 
ual peripheral  progression  and  perforation  of  the  skin  from  within 
outwardly.  The  excavated  ulcer  is  thus  formed  ;  as  before  stated,  this 
is  a  diminutive  cold  abscess. 

Just  as  often  the  process  is  in  the  superficial  layers  of  a  membrane, 
and  we  have  the  02:)e)i  cutaneous  ulcer.     We  will  illustrate  this  by  ian 


ANATOMY  OF   ULCERS. 


481 


exanijDle.  Let  us  supjDose  that  from  any  of  the  above-mentioned 
causes  we  have  a  chronic  inflammation  in  the  skin  of  the  leg,  say  on 
the  anterior  surface  of  its  lower  third.  The  skin  is  traversed  by  di- 
lated vessels,  hence  it  is  redder  than  normal,  it  is  swollen,  partly 
from  serous,  partly  from  plastic  infiltration,  and  it  is  sensitive  to 
pressure.  Wandering  cells  ai-e  infiltrated,  especially  in  the  superficial 
parts  of  the  cutis  ;  this  renders  the  papillas  longer  and  more  succulent ; 
the  development  of  the  cells  of  the  rete  Malpighii  also  becomes  more 
plentiful,  its  superficial  layers  do  not  pass  into  the  normal,  horny 
state ;  the  connective  tissue  of  the  papillary  layer  is  softer  and  be- 
comes partly  gelatinous.  Now,  slight  fiiction  at  any  point  suffices 
to  remove  the  soft,  thin,  horny  layer  of  the  epidermis.  This  exposes 
the  cell  layer  of  the  rete  Malpighii ;  new  irritation  is  set  up,  and  the 
result  is  a  suppurating  surface,  whose  upper  laj^er  consists  of  wan- 
dering cells,  the  lower  of  greatly  degenerated  and  enlarged  cutane- 
ous papillge.  If  at  this  stage  the  part  be  kept  at  perfect  rest,  and 
protected  fxom  further  irritation,  the  epidermis  would  be  gradually 
regenerated,  and  the  still  sujDerficial  ulcer  would  cicatrize.  But 
usually  the  slight  superficial  wound  is  too  little  noticed,  it  is  exposed 
to  new  irritations  of  various  kinds ;  there  are  suppuration  and  molecu- 
lar destruction  of  the  exposed  inflamed  tissue,  then  of  the  papillfe 
and  the  result  is  a  loss  of  substance  which  gradually  grows  deeper 
and  wider ;  the  ulcer  is  fully  formed.  The  accompanying  figure  is 
the  section  of  a  spreading  ulcer  of  the  skin ;  it  formed  the  basis  of 
this  description  (Fig.  T2). 

J<1G.  72. 


Cntancous  ulcer  of  the  le<r.    'Magnified  100  diameters  ;  after  Forster.    Atlas,  Taf  XI. 


At  a  you  see  the  cutis  already  somewhat  thickened,  toward  h 
its  papillae  are  enlarged,  w-hile  the  vascular  loops  increase,  and  the 
connective  tissue  is  more  richly  strewn  with  cells ;  at  5  is  the  fully- 
formed  ulcerated  surface;  at  c  the  epidermis  is  much  thickened  and 
forms  the  indurated  border  of  the  ulcer. 
32 


482 


ULCERS. 


On  the  mucous  membrane  the  process  is  the  same :  at  first  there 
is  a  lively  emigration  of  young  cells  on  the  surface ;  this  is  soon  ac- 
companied  by  a  moderate  degree  of  serous  and  plastic  infiltration  in 
the  connective  tissue  of  the  mucous  membrane ;  the  mucous  glands 
secrete  plentifully.  As  already  stated,  it  was  believed,  until  within  a 
short  time,  that  catarrhal  pus  was  of  a  purely  epithehal  character ; 
now  there  is  rather  an  inclination  to  the  view-  that  the  elements  of 
catarrhal  secretion  also  are  wandering  white  blood-corpuscles.  Con- 
tinued irritation  of  a  mucous  membrane  affected  with  catarrh  is 
followed  by  softening  and  breaking  down  of  the  tissue,  as  we  de- 
scribed to  be  the  case  in  the  cutis ;  then  we  have  a  catarrhal  ulcer. 

There  is  another  and  more  acute  mode  of  formation  of  ulcers,  viz. : 
from  pustules  that  do  not  heal,  but  which  enlarge  after  evacuation  of 
the  pus,  and  keep  up  an  acute  inflammatory  character,  as  the  soft 
chancrous  ulcer.  And  such  ulcers  resulting  from  ecthj-ma  pustules, 
without  any  preceptible  specific  dyscrasia,  are  particularly  frequent 
on  the  legs  of  young,  full-blooded,  and  otherwise  healthy  persons ;  we 
know  nothing  definite  about  their  causes  ;  they  often  have  a  prolifera- 
tino-  fungous  form,  but  at  other  times  induce  rapid  destruction  of  tis- 
sue. But  this  acute  commencement  of  ulcers  is  much  rarer  than  the 
chronic.  Some  diseases  are  only  half-correctly  called  ulcers,  as  the 
"  typhous  ulcer ; "  in  typhoid  fever  there  is  an  acute  progressive  in- 
flammation of  Fever's  plaques,  which  in  many  cases  ends  in  gangrene, 
with  necrosis  of  the  inflamed  portion  of  mucous  membrane  ;  what  re- 
mains after  throwing  off  of  the  slough  is  a  granulating  surface,  which 
usually  cicatrizes  rapidly ;  strictly  speaking,  this  granulating  surface 
is  not  an  ulcer,  it  only  becomes  so  when  it  does  not  heal  normally. 
Of  this,  more  hereafter ;  we  may  use  these  expressions  more  fi-eely, 
when  we  understand  the  process  perfectly. 

From  this  description  you  see  that,  in  ulceration  as  in  inflamma- 
tion^ two  opposite  processes  are  combined — new-formation  and  de- 
struction; the  latter  results  from  liquefaction  of  the  tissues,  i.  e., 
through  suppuration,  or  molecular  disintegration,  or  both  together. 
There  can  be  no  doubt  of  the  antagonistic  relations  of  new  formation 
and  destruction  to  each  other  in  the  examples  adduced,  for  it  is  evi- 
dent that  there  the  former  preceded  the  latter.  But  you  may  also 
imagine  that  in  a  previously  healthy  portion  of  skin  there  might  be 
a  disturbance  of  nutrition  of  such  a  nature  that  disintegration  of  tis- 
sue is  the  first  step,  as  you  have  already  learned  from  the  section  on 
gangrene.  Then  on  the  border  of  the  healthy  portion  of  skin,  which 
retains  its  vitality,  there  is  a  new  formation  of  young  cells,  and,  if  the 
parts  adjacent  to  the  primarily  necrosed  spot  be  healthy,  there  must 
result  a  granulation  surface;  but,  if  the  parts  be  not  healthy,  and  have 


NOMENCLATUEE   OF   ULCERS.  483 

only  a  slight  amount  of  vitality,  there  also  we  shall  have  disinlegra- 
tion  instead  of  active  inflammatory  new  formation ;  an  ulcer  will  thus 
be  formed  which  will  spread  gradually.  This  course,  of  an  ulcer 
occurring  primarily  with  molecular  disintegration  without  precedent 
cellular  infiltration,  rarely  presents  itself  in  practice.  Strictly  speak- 
ing, molecular  disintegTation  and  gangrene  are  but  quantitative  varie- 
ties of  the  same  process,  viz.,  the  death  of  certain  portions  of  tissue ; 
cases  occur  where  ulceration  and  gangrene  are  very  closely  associated, 
as  in  hospital  gangrene,  of  which  we  have  already  spoken ;  but,  as 
before  said,  an  inflammatory  infiltration  usually  precedes  the  disin- 
tegration. 

The  above  observations,  which  show  the  relation  of  ulceration  on 
the  one  hand  to  the  new  formation,  on  the  other  to  the  gangrene,  will 
have  rendered  evident  the  difficulty  of  preserving  systematic  divisions 
of  the  course  of  this  disease.  But  do  not  be  afraid  that  I  am  going 
to  confuse  you :  we  will  enter  at  once  on  the  special  pecuHarities  of 
ulcers,  you  will  understand  then  more  readily ;  here  we  shall  only  add 
that,  according  to  the  vital  process,  all  ulcers  may  be  divided  into  two 
chief  varieties,  viz.,  those  where  the  new  formation  predominates, 
which  we  shall  designate  briefly  as  proliferating  ulcers^  and  those 
where  suppuration  and  disintegration  are  more  prominent,  which  we 
shall  call  atonic  or  torpid  ulcers.  Between  these  two  extreme  boun- 
dary-points of  the  anatomical  and  vital  peculiarities  of  ulcers,  there 
are  numerous  intermediate  forms. 

To  induce  healing  of  an  ulcer,  the  first  requirement  is  arrest  of 
the  disintegration  on  the  surface,  next  that  the  floor  of  the  ulcer  as- 
sume, at  least  approximately,  the  character  of  a  healthy  granulating 
surface,  which  goes  on  to  cicatrize  in  the  usual  way.  In  torpid,  atonic 
ulcers  it  is  also  absolutely  necessarj'^  that  there  should  be  a  free  de- 
velopment of  vessels  and  stronger  cells,  which  do  not  lead  to  sup- 
puration, but  to  connective-tissue  new  formation;  in  proliferating 
ulcers,  on  the  other  hand,  the  new  formation  must  be  brought  back  to 
the  normal  size.  As  you  wUl  readily  perceive,  on  reflection,  this  gives 
the  indication  for  the  local  treatment  to  be  followed  in  either  case,  to 
which  we  shall  soon  refer. 

The  nomenclature  of  lilcers  varies  greatly,  according  to  the  pecu- 
liarities that  are  made  especially  prominent.  From  the  mode  of  ori- 
gin, just  as  in  other  chronic  inflammations,  we  may  distinguish  two 
classes,  or  chief  varieties,  viz.,  idiopathic  and  symptomatic  ulcers. 
Idioj)athic  ulcers  are  such  as  result  from  purely  local  irritation ;  they 
may  also  be  termed  irritative  ulcers.  Symptomatic  ulcers  are  such  as 
from  some  dyscrasia  appear  as  a  symptom  of  constitutional  disease, 
without  the  action  of  a  local  irritation  on  the  afiected  part.     Tliis  di- 


484 


ULCERS. 


vision  of  the  causes  of  ulcers  is,  as  already  stated,  the  same  that  we 
have  previously  studied  in  chronic  inflammation. 

Let  us  at  present  leave  out  of  consideration  these  etiological  con- 
ditions, and  seek  first  of  all,  by  attending  to  the  external  appearances 
that  an  ulcer  may  ofi'er,  to  give  a  more  perfect  representation. 

I  will  only  add  here  that  ulceration  may  not  only  occur  in  normal 
tissue  but  also  in  new  growths  in  tumors  proper ;  both  excavated  and 
superficial  ulcers  may  form  in  and  on  them.  In  describing  an  ulcer, 
the  following  parts  are  distinguished : 

1.  Form  and  extent  of  the  ulcer.  It  may  be  circular,  crescentic, 
quite  irregular,  ring-shaped,  superficial,  deep ;  it  may  be  a  canal,  lead- 
ing into  the  deeper  parts,  a  tubular  ulcer,  a  fistula ;  as  I  have  already 
told  you,  these  fistulas  result  from  the  formation  of  a  point  of  inflam- 
mation in  some  deep  parts,  in  a  deep  layer  of  the  cutis,  in  the 
subcutaneous  tissue,  muscles,  periosteum,  or  bones,  or  even  in  the 
glands,  and  gradually  ulcerating  through  till  it  reaches  the  surface. 
Hence  fistula  is  always  preceded  by  the  formation  of  an  excavated  xil- 
ser,  of  a  more  or  less  deeply-seated  point  of  ulceration. 

2.  The  base  and  secretion  of  the  ulcer.  The  base  may  be  shallow, 
deep,  or  projecting;  it  may  be  covered  with  dirt}^,  badly-smelling 
serous,  sanious  fluid,  or  even  with  gangrenous  tags  of  tissue  (sanious 
ulcers) ;  an  amorphous,  fatty,  creamy,  or  smeary  substance  may  cover 
it;  it  may  also  have  luxuriant  granulations  with  a  muco-purulent 
secretion  (fungous  ulcers). 

3.  The  edges  of  the  ulcer  are  flat  or  elevated,  wall-like,  hard 
{callous  ulcers),  soft,  tortuous  (sinuous  ulcers),  zigzag,  everted,  under- 
mined, etc. 

4.  T7ie  vicinity  of  the  ulcer  may  be  normal  or  inflamed,  oedema- 
tous,  indurated,  pigmented,  etc. 

These  universally  employed  technical  terms  suffice  for  the  de- 
scription of  any  ulcer  to  a  scientific  person.  But,  as  the  terms  ex- 
pressing the  -vitality  of  the  process,  as  torpid,  atonic,  proliferating, 
fungous,  etc.,  are  briefer,  they  are  more  frequently  employed  ;  desig- 
nations referring  to  the  ultimate  causes,  especially  of  syniptomatic 
ulcers,  are  also  often  used.  Thus  we  speak  of  scrofulous,  tuberculous, 
syphilitic,  etc.,  ulcers. 

Wliile  we  have  the  local  conditions  of  ulcers  fresh  in  our  memory, 
we  shall  speak  of  local  remedies,  as  far  as  their  employment  depends 
on  the  condition  of  the  ulcer.  A  large  number  of  ulcers,  especially 
of  those  tliat  have  resulted  from  repeated  local  irritations,  heal  very 
readily.  As  soon  as  the  diseased  parts  are  under  favorable  external 
circumstances,  and  not  subject  to  new  irritation,  cicatrization  often 
begins   spontaneously.     It  is  remarkable  how  rapidly  the   common 


LOCAL   REMEDIES.  .  435 

nicer  of  the  leg  begins  to  improve  in  appearance  as  soon  as  the  patient 
has  taken  a  warm  bath,  simply  applied  a  wet  compress  to  the  ulcer, 
and  remained  in  bed  quietly  for  twenty-four  hours.  The  ulcer,  which 
preWously  looked  dirty  or  graj-ish-green,  and  had  a  pestilent  odor, 
looks  quite  differently ;  it  has  a  tolerably  fair  if  not  very  actively  gran- 
ulating surface,  and  secretes  good  pus ;  a  fortnight's  rest  and  great 
cleanliness  sometimes  suffice  for  a  perfect  cure  of  small  ulcers  of  this 
kind.  But  the  patient  is  hardly  dismissed,  and  in  his  old  mode  of 
life,  before  the  cicatrix  again  opens,  and,  in  a  few  days,  his  condition 
is  as  bad  as  ever.  So  it  goes  on :  the  patient  again  enters  the  hos- 
pital, and  is  again  dismissed,  to  be  again  received  in  a  short  time 
We  have,  however,  some  means  of  protection  against  these  relapses, 
of  which  we  shall  speak  hereafter.  All  ulcers  are  not  inclined  to  heal 
so  quickly  ;  many  require  various  remedies  and  a  long  treatment.  We 
shall  now  run  through  the  various  forms,  according  to  their  local 
symptoms,  and  mention  the  local  remedies  to  be  employed. 

1.  The  ulcer  with  inflamed  borders^  and  the  .erethitic  idcer.  Fre- 
quently, while  the  patient  is  constantly  going  about,  an  ulcer  ap- 
pears very  red  and  painful,  and,  after  a  period  of  rest,  this  slight 
amount  of  inflammation  spontaneously  subsides.  But  there  are  other 
ulcers  whose  borders  are  constantly  red  and  sensitive,  the  ulcer  bleeds 
easily,  and  the  granulations  are  painful  to  the  touch.  Such  vilcers  are 
called  erethitic  or  irritable  j  the  highest  grades  of  erethism  of  the 
surface  of  the  ulcer  are  very  rare ;  in  Zurich,  I  had  a  patient,  who,  as 
a  sequent  of  a  severe  inflammation  in  the  thigh,  lost  a  large  portion 
of  skin  by  gangrene ;  after  the  detachment  of  the  eschar,  there  was 
left  a  very  luxuriantly  proliferating,  granulating  surface,  with  httle 
tendency  to  heal,  which  was  so  painful  to  the  lightest  touch  that  the 
patient  would  cry  out  and  shrink  away.  The  cause  of  this  excessive 
sensitiveness  in  such  cases  has  ah-eady  been  mentioned  when  speaking 
of  nerv'e  cicatrices. 

In  treating  inflamed  and  erethitic  ulcers,  we  first  try  mild  salves 
of  fresh  butter  and  wax,  unguentum  cereum,  then  so-called  cooling 
salves,  such  as  those  of  zinc  and  lead,  also  fomentations  with  lead- 
water  ;  if  under  this  treatment  the  granulations  continue  painful  and 
look  badly,  while  the  inflammation  of  the  surrounding  parts  is  less, 
we  may  cauterize  the  sm'face  of  the  ulcer  freely  with  nitrate  of  silver, 
or,  still  better,  with  the  hot  iron ;  the  latter  remedy,  with  subsecpent 
compression  by  adhesive  plaster,  finally  caused  healing  in  the  case 
above  mentioned.  In  such  cases,  the  local  erajjlojanent  of  narcotics 
is  usually  recommended,  such  as  cataplasms,  with  the  addition  of  bel- 
ladonna, hyoscyamus,  opium,  etc.,  but  these  remedies  do  so  \evj  little 
good,  that,  in  my  opinion,  their  employment  is  only  time  lost. 


486 


ULCERS. 


2.  Fungous  ulcers^  i.  e.,  those  whose  granulations  are  fungous  and 
proliferating,  and  project  above  the  level  of  the  skin.  These  ulcers 
secrete  a  muco-pus,  and  are  very  vascular. 


Fig.  73. 


Blood-vessels  of  two  luxuriant  granulations  of  a  common  (not  cancerous)  nicer  of  the  leg,  arti- 
ficially injected  by  Thiersch  (Epitlieiial  cancer,  Plate  XL,  Fig.  4). 


In  these  cases  we  may  use  astringent  remedies  and  compresses  wet 
with  decoction  of  Peruvian  or  oak  bark,  but  they  are  of  only  moderate 
benefit.  It  is  best  to  destroy  the  surface  of  such  granulations  by  caus- 
tics ;  daily  applications  of  the  solid  stick  of  nitrate  of  silver  usually 
suffices,  where  it  does  not,  we  may  resort  to  caustic  potash  or  the  hot 
iron.     Compression  with  adhesive  plaster  is  often  very  efficacious. 

3.  Callous  ulcers  are  most  dreaded  by  surgeons,  on  account  of 
the  long  treatment  they  require ;  they  are  those  whose  base,  edges, 
and  vicinity,  have  become  thickened  and  of  cartilaginous  hardness, 
from  the  long  duration  of  chronic  inflammation.  The  ulcer  is  torpid, 
and  usually  lies  deep  below  the  surface ;  the  edges  are  sharply 
bounded.  The  indicatioi:is  for  treatment  are  twofold :  first,  to  soften 
the  tendinous,  non-vascular  tissue  of  the  hardened  borders  and  base 
of  the  ulcer ;  and  to  induce  a  proper  amount  of  vascularity  in  these 
parts.  We  meet  ulcers  of  this  variety  that  have  lasted  twenty 
years  or  more ;  in  such  cases  we  may  employ  the  following  treat- 
ment :  compression,  best  with  strips  of  adhesive  plaster  apphed  in  a 
certain  way,  as  you  will  see  done  in  the  clinic.  This  dressing,  which 
should  cover  not  only  the  ulcer  but  the  entire  leg,  may  at  first  be  left 
on  a  day  or  two,  but  later,  when  the  ulcer  begins  to  heal,  it  may  re- 
main untouched  for  three   or  four  dajs,  or  longer.      This  so-called 


CALLOUS  ULCERS.  487 

Baynton  dressing  of  adhesive  plaster  is  of  great  service  m  iilcers  o\ 
the  leg,  evspecially  for  those  cases  where  the  patients  are  not  inclined 
to  lie  still,  but  must  attend  to  their  business.  In  the  surgical  poli- 
clinic of  Berlin  I  made  some  observations  on  this  treatment  of  ulcers 
of  the  leg,  but  cannot  report  so  favorably  on  it,  as  a  means  of  cure^ 
as  has  been  done  by  other  surgeons — they  seem  to  claim  that  this 
dressing  is  an  almost  universal  remedy  in  ulcers  of  the  leg.  I  prize 
it  greatly  as  a  protective  dressing  in  dispensary  practice,  because  it 
enables  the  patient  to  go  about,  A\dthout  the  ulcer  spreading ;  but  I 
cannot  see  that  all  ulcers  heal  particularly  well  under  this  dressing,  or 
that  the  action  of  the  adhesive  plaster  on  the  callous  borders  of  the 
ulcer  is  more  eflFective  than  the  remedies  which  I  shall  mention  after 
a  while.  The  best  remedy  for  keeping  up  constant  congestion  in  the 
ulcer,  and  thus  increasing  the  formation  of  vessels  and  cells,  is  moist 
warmth,  which  you  may  use  in  the  form  of  cataplasms,  or,  still  better, 
as  a  continued  warm-water  bath.  I  would  particularly  recommend 
the  latter  to  you,  for  by  it  you  at  the  same  time  obtain  an  artificial 
swelling  and  softening  of  the  dry,  hardened  borders  of  the  ulcer. 
Zeis,  who  has  often  employed  the  warm-water  bath  in  callous  ulcers 
of  the  leg,  also  recommends  this  treatment  as  one  of  the  most  effi 
cacious  in  such  cases.  It  is  sometimes  very  important  to  destroy  the 
callous  edges  entirely,  or  to  excite  in  them  a  high  degree  of  purulent 
inflammation.  The  former  you  may  most  quickly  accomplish  by  the 
hot  iron,  the  latter  by  repeated  application  of  tartar-emetic  ointment 
or  emplastrum  cantharidis.  If  a  pustulous  or  even  gangrenous  inflam- 
mation of  the  ulcer  and  its  vicinity  be  induced  by  the  latter  reme- 
dies, place  the  foot  in  a  water-bath  and  you  will  often  obtain  a  very 
quick  cure. 

It  is  not  always  possible  to  obtain  healing  of  a  callous  ulcer  of 
the  leg ;  and  ulcers  along  the  anterior  face  of  the  leg,  extending  to 
the  periosteum  of  tlie  tibia,  are  especially  intiactable  ;  those  ulcers  also 
which  surround  the  leg  like  a  ring  are  usually  reckoned  as  incurable  ; 
they  are  considered  as  indications  for  amputation  when  they  perma- 
nently prevent  the  patient  from  walking  or  attending  to  his  business. 
Besides  the  above-mentioned  circumstances  there  is  still  another,  that 
impedes  the  healing  of  ulcers  with  greatly-indurated  borders,  that  is 
that  the  healing  granulating  surface  and  cicatrix  do  not  diminish  and 
thicken  by  contraction,  because  the  firmness  of  the  surrounding  po]> 
tions  of  skin  permits  no  displacement ;  while,  as  you  know,  all  granu- 
lating wounds  decrease  to  about  half  their  size  by  contraction,  and 
nence  the  cicatizing  surface  grows  smaller,  in  many  cases  the  granu- 
lating sm-face  of  these  ulcers  must  cicatrize  throughout  its  entire  ori- 
ginal extent,  because  it  cannot  contract.     To  render  this  contraction 


488 


ULCERS. 


possible,  deep  incisions  have  been  made  tbrougli  the  skin  around  the 
ulcer,  and  these  incisions  have  been  kept  open  by  the  introduction  of 
charpie ;  I  have  never  seen  any  great  benefit  from  this  treatment. 
As  a  consequence  of  the  rigidity  also,  the  new  cicatrix  is  not  suffi- 
ciently dense  and  readily  reopens,  so  that  the  ulcer  once  healed  soon 
develops  again.  To  guard  against  this  it  is  best  to  cover  the  cicatrix 
with  wadding  and  ajDply  a  starch-bandage.  This  dressing  should  be 
worn  six  or  eight  weeks,  tiU  the  cicatrix  is  firm  and  well  organized. 
I  have  followed  this  practice  for  a  long  time  in  all  cases  of  ulcer  of  the 
leg,  and  have  every  reason  to  be  satisfied  Avith  it. 

4.  Suppurating  ulcers.  The  causes  of  decomposition  taking 
place  on  the  surface  of  an  ulcer  are  often  due  to  unfavorable  ex- 
ternal circumstances  ;  but,  in  other  cases,  from  constitutional  causes, 
there  is  a  tendency  to  more  rapid  disintegTation  of  the  tissue  on  the 
surface  of  the  ulcer.  Solution  of  chloride  of  lime,  pyroligneous  acid, 
turpentine,  spirits  of  camphor,  and  carbolic  acid,  are  the  remedies  to 
be  applied  in  such  cases.  If  the  destruction  of  the  tissue  go  on  very 
rapidly,  so  that  the  ulcer  enlarges  greatly  from  one  day  to  another,  it 
is  called  an  eating  or  phagedenic  ulcer  ;  this  form  closely  resembles 
hospital-gangrene  above  mentioned.  In  some  cases  sprinkling  pow- 
dered red  precipitate  of  mercury  quickly  arrests  the  disintegration ; 
should  it  not  do  so,  I  would  advise  not  to  postpone  the  destruction  of 
the  entire  ulcer  ;  free  cauterization  with  caustic  potash  or  the  hot  iron, 
destroying  the  edges  of  the  ulcer  down  to  the  healthy  tissue,  almost 
always  proves  effective  in  these  cases. 

5.  Sinuous  and  fistulous  ulcers — ulcers  with  exca^'ated  edges  and 
fistulse.  They  always  begin  as  abscesses,  which  gradually  break 
through  from  -within  outward,  and  are  particularly  apt  to  depend  on 
clu-onic  suppuration  of  Ij^mphatic  glands.  Such  an  ulcer  will  always 
heal  more  rapidly  if  you  make  an  open  ulcer  of  it,  by  cutting  away 
the  edges  of  skin,  which  are  usually  thin  and  luidermined,  or,  if  they 
are  too  thick  for  you  to  do  this,  at  least  spHt  up  the  cavity  and  expose 
the  deeply-seated  ulcer.  This  treatment  also  answers  for  fistulous 
ulcers  when  they  lead  to  abscesses ;  the  latter  must  heal  before  the 
fistula  can  close  firml3\  Let  me  remark,  in  parenthesis,  the  word 
"  fistula  "  has  still  another  meaning,  as  it  is  appHed  to  any  tube-like 
abnormal  opening  that  leads  to  any  cavity  of  the  body ;  thus  we 
Bpeak  of  breast,  brain,  gall-bladder,  intestinal,  vaginal,  urinary,  ure- 
thral, and  other  fistulae. 

We  have  still  to  consider  a  very  important  part  of  the  chapter  on 
ulcers,  viz.,  the  etiology.  I  have  already  told  you  that  we  have  to 
distinguish  local  and  constitutional  causes,  just  as  in  chronic  inflam- 


CAUSES  OF  ULCERS.  489 

mation.  Hence  all  tlie  causes  that  induce  chronic  inflammatiou  are 
again  to  be  enumerated  here ;  we  will  call  particular  attention  to  a 
few  of  these.  If  we  first  consider  more  carefully  the  local  causes  of 
ulcers,  the  most  important  of  them  is  continued  mechanical  or  chemi- 
cal local  irritation.  Continued  friction  and  irritation  are  frequent 
causes  of  such  irritable  ulcers  ;  a  tight  boot,  the  hard  edge  of  a  shoe, 
may  induce  ulcers  on  the  feet ;  a  rough  tooth  or  a  sharp  piece  of  tar- 
tar may  cause  ulcers  of  the  mucous  membrane  of  the  mouth  or  tongue, 
etc.  Ulcers  of  this  variety  usually  bear  the  marks  of  irritation ;  the 
vicinity  is  red  and  painful,  as  is  the  ulcer  itself.  Among  the  chemical 
irritants  we  have  the  action  of  schnaps  and  rum  on  the  gastric  mucous 
membrane ;  as  a  rule,  topers  have  constant  gastric  catarrh,  during 
whose  course  catarrhal  and  sjoecific  ulcers,  of  various  kinds,  not  unfi-e- 
quently  form.  A  second  and  still  more  frequent  cause  of  chronic 
inflammation,  resulting  in  ulceration,  is  congestion,  especially  venous 
congestion,  distention  of  the  veins,  varicose  veins.  These  are  very 
intimately  connected  with  the  origin  of  ulcers  of  the  leg ;  we  shall 
speak  of  them  later  (Chapter  XIX).  There  we  wUl  only  mention  that, 
as  a  result  of  the  continued  distention  of  the  small  cutaneous  veins, 
there  is  chronic  serous  infiltration  of  the  skin,  to  which  is  gradually 
added  cellular  infiltration,  thickening ;  and,  lastlj^,  there  are  frequently 
sujipuration  and  disintegration. 

Ulcers  due  to  varices,  which  are  generally  briefly  termed  varicose 
ulcers^  TCiVij  have  very  varied  characteristics.  At  first  they  are  ordi- 
narily simple,  often  proliferating  ulcers ;  subsequently  they  assume  a 
more  torpid  character,  and  then  the  borders  become  callous.  We  have 
already  noticed  how  quickly  such  ulcers  change  when  they  are  only 
treated  by  rest  and  cleanliness.  In  regard  to  treatment,  the  already- 
lauded  dressings  with  adhesive  plaster  are  excellent  both  for  inducing 
healing  of  the  ulcer  and  arresting  further  development  of  the  varices. 
But  in  most  cases  I  prefer  yest  in  bed,  on  the  principles  above  given, 
and  only  subsequently  apply  the  adhesive  plaster  to  prevent  further 
increase  of  the  varices. 

Although  we  have  here  shown  the  intimate  relations  between 
varicose  veins  and  ulcers,  and  have  thus  called  attention  to  the  point 
of  greatest  practical  importance  about  this  disease  of  the  veins,  you 
must  not  conclude  that  varices  are  always  followed  by  ulceration ;  on 
the  contrary,  there  are  many  cases  of  enormous  varices  that  are  not 
followed  by  secondary  ulcers. 


We  come  noAV  to  a  short  description  of  those  ulcers  that  are  due 
to  internal  causes,  and  are  connected  with  various  dyscrasia — the 
mjinptomatic  ulcers. 


490  ULCERS. 

1.  First  among  these  are  scrofulous  ulcers  j  these  most  frequently 
come  m  the  neck,  enclosed  collections  of  pus  developing  in  the  cutis 
or  subcutaneous  tissue,  and  gradually  perforating  out  through  the 
skin.  Of  course,  this  causes  small  losses  of  skin,  whose  edges  are 
usually  red  and  very  thin,  and  which  lead  to  deeply-seated  cavities 
that  evacuate  thin  pus  or  tissue  that  has  undergone  caseous  degen- 
eration. The  borders  of  these  cutaneous  ulcers  are  excavated,  as  may 
readily  be  sho'svn  by  examining  with  the  probe.  As  a  rule,  these  are 
tj^pical  atonic  ulcers.  From  this  descrijDtion  you  see  that  this  form  of 
undermined  sinuous  ulcers  is  only  due  to  the  mode  of  origin,  and  may 
occasionally  present  itself  under  the  most  varied  constitutional  con- 
ditions ;  although  experience  teaches  that  it  is  especially  frequent  in 
scrofulous  persons,  and  this  is  why  such  atonic  ulcers  with  under- 
mined edges  are  referred  to  scrofula.  This  conclusion  will  generally 
prove  correct,  though  it  is  not  necessarily  the  case. 

2.  Lupous  ulcers.  By  lupus  we  understand  a  disease  which 
manifests  itself  by  the  development  of  small  nodules  in  the  superficial 
layer  of  the  skin.  The  subsequent  progress  of  these  nodules  may 
vary.  They  consist  of  collections  of  wandering  cells  and  coincident 
ectasia  of  the  vessels.  Lupous  nodules  may  (a)  enlarge  and  run 
together,  so  as  to  form  larger  nodules  and  tuberculous  thickenings  of 
the  skin  {Lupus  hypertrophicus)  y  {h)  on  their  surface  there  is  a  free 
exfoliation  of  epidermis  {Z/upus  exfoliatus)  /  (c)  the  surface  ulcerates 
[Lupus  exulcercms).  All  three  forms  may  combine,  and  some  others 
may  be  added  to  them.  The  ulcers  resulting  from  the  latter  form  may 
be  accompanied  by  strongly  proliferating  granulations  [Liqnis  exul- 
cerans  fungosus),  or  dispose  to  a  more  rapid  destruction  of  tissue 
(Liqms  exedens,  vorax).  The  disease  is  most  frequent  on  the  face, 
especially  on  the  nose,  cheeks,  and  lips ;  it  causes  the  most  fiightful 
disfigurement.  The  nose  or  the  lips  may  be  entirely  destroyed  by 
lupus.  I  saw  one  case  where  all  the  skin  of  the  face,  nose,  lips,  and 
eyehds,  was  destroyed ;  both  eyes  had  been  lost  by  suppuration,  and 
the  facial  part  of  the  skull,  being  exposed,  presented  a  most  horrible 
sight.  Dieffenhach  describes  such  a  case  in  a  PoKsh  count,  and  com- 
pares his  appearance  to  that  of  a  death's  head.  Lupous  ulcers  do 
not  by  any  means  always  look  alike ;  but  their  surroundings,  and  the 
general  appearance  of  the  portion  of  skin  diseased,  greatly  facilitate 
the  diagnosis.  When  lupus  occurs  in  other  parts  of  the  body,  as  in  the 
extremities  or  mucous  membranes,  as  the  throat  or  conjunctiva,  the 
diagnosis  is  difficult,  and  cannot  always  be  made  positively.  It  is  not 
only  pardonable,  but  sometimes  unavoidable,  to  mistake  the  disease 
on  the  extremities  for  certain  forms  of  leprosy,  and  in  the  throat  for 
sj-philitic  ulcers.     In  most  cases  lupus  is  due  to  a  dyscrasia.     It  is 


LUPUS. 


491 


rarely  a  purely  local  skin-disease.  It  is  doubtful  wliether  we  are  jus- 
tified in  claiming  a  particular  lupous  dyscrasia,  for  lupus  very  often 
attacks  scrofulous  persons,  so  that  it  may  be  regarded  as  one,  and  one 
of  the  worst  symptoms  of  scrofula.  It  also  comes  as  one  symptom  of 
s;y^hilis,  so  that  lupus  syphiliticus  and  lupus  scrofulosus  are  spoken 
of.  Lupus  is  most  frequent  din-ing  puberty,  and  attacks  females 
oftener  than  males ;  it  more  rarely  develops  late  in  life  ;  beyond  the 
fortieth  year  we  are  pretty  safe  from  it. 

In  the  way  of  treatment  I  attach  most  importance  to  local  treat- 
ment, especially  in  the  ulcerative  form,  for  here  we  must  make  every 
attempt  to  arrest  the  progress  of  destruction,  which  may  endanger  all 
the  skin  of  the  face,  and  internal  remedies  act  very  slowly.  Here,  as 
in  all  rapidly-spreading  ulcerations,  we  should  radically  destroy  the 
base  and  edges  of  the  ulcer  by  cauterizing  down  to  the  healthy  tis- 
sue. We  generally  employ  the  potential  cautery  and  the  solid  stick 
of  nitrate  of  silver  or  caustic  potash,  pushing  them  through  the  lupus 
into  the  healthy  parts  below.  We  may  also  use  the  caustic  in  the 
form  of  paste,  such  as  chloride-of-zinc  paste,  which  is  most  readily 
made  by  mixing  chloride  of  zinc  with  rye  or  wheat  flour,  and  making 
it  into  paste  with  a  few  drops  of  water,  then  spreading  it  on  the  ulcer. 
To  attain  pur  object  more  rapidly,  and  let  the  caustic  act  more  in- 
tensely, it  is  advisable  to  scratch  up  the  floor  of  the  ulcer  with  the 
flat  end  of  a  probe,  and,  after  arresting  the  bleeding,  apjDly  the  caus- 
tic. Of  the  remedies  above  mentioned,  I  prefer  caustic  potash,  as  it 
unites  with  the  tissues  most  rapidly,  and  consequently  the  pain  ceases 
sooner.  This  cauterization  may  be  done  during  anaesthesia,  so  that 
when  the  patient  awakes  there  will  be  a  moderate  and  tolerable  burn- 
ing. Nitrate  of  silver  causes  the  most  protracted  sufi"ering,  but  has 
the  advantage  of  liquefying  less  rapidly  than  caustic  potash,  and  hence 
possesses  special  advantages  for  cauterizing  some  portions  of  the 
body.  When  the  slough  from  the  cauterization  is  detached,  if  the 
operation  was  thoroughly  done,  there  is  left  a  good  granulating  sur- 
face, which  cicatrizes  in  the  ordinary  manner.  A  new  lupus  is  not 
apt  to  form  in  this  cicatrix,  although  cauterization  cannot  prevent  the 
development  of  new  nodules  in  the  vicinity.  Painting  with  tinctuie 
of  iodine  is  the  best  local  remedy  in  exfoliative  and  hypertrophic 
lupus.  It  is  well  to  mix  this  remedy  with  glycerine,  to  render  its  ac- 
tion less  intense.  I  have  repeatedly  seen  lupus  nodules  shrivel  up 
under  this  treatment,  but  it  does  not  prevent  relapses.  Lastly,  in 
some  cases,  the  portion  of  lupous  skin  may  be  excised  with  advan- 
tage. The  only  internal  remedy  from  which  I  have  seen  benefit  is 
cod-Hver  oil,  of  which  four  to  six  table-spoonfuls  are  to  be  given  daily, 
but  this  treatment  must  be  continued  for  j^ears.     Decoctions  of  barks 


492  ULCERS 

are  only  useful  in  lupus  syphiliticus.  Arsenic,  which  is  highly  prized 
in  other  chronic  skin-diseases,  is  of  little  use  in  lupus.  In  Switzer- 
land the  disease  was  rare.  My  experience  of  it  w^as  chiefly  derived  in 
the  Berlin  clinic,  and,  if  I  were  to  state  my  belief  regarding  the  effi- 
cacy of  internal  treatment,  it  would  be  to  the  effect  that  the  lupous 
dyscrasia,  like  the  scrofulous,  often  disappears  spontaneously  in  the 
course  of  time,  but  is  also  often  incurable. 

3.  Sooi'hutic  ulcers.  Scorbutus,  or  scurvy,  is  a  disease  which,  as  al- 
ready stated,  when  fully  developed,  manifests  itself  by  great  weakness 
of  the  capillary  vessels.  There  are  extravasations  of  blood  at  many 
places  in  the  skin  and  muscles ;  the  gums  swell,  become  bluish  red, 
and  ulcers,  which  bleed  readily,  form  on  them  ;  there  are  also  intes- 
tinal liEemorrhages,  general  emaciation  and  debility,  and  many  patients 
die  in  a  miserable  state.  This  severe  form  of  scorbutus  occurs  chiefly 
endemically  on  the  coasts  of  the  Baltic,  and  in  sailors  on  long  voy- 
ages. In  the  latter  case  the  disease  is  usually  referred  to  continued 
use  of  salt  meat.  Inland  there  is  a  sort  of  acute  scorbutus,  comprising 
morbus  maculosus,  purpura,  etc.  Scorbutus  localized  on  the  gnims 
and  oral  mucous  membrane  is  everywhere  common  among  children ; 
the  gums  swell,  become  of  a  dark  bluish  red,  bleed  on  the  least  touch, 
and  vilcers,  covered  with  a  yellow,  smeary  coating  of  pus,  fungi,  and 
shreds  of  tissue,  form  on  them.  When  the  disease  appears  in  this 
form,  and  is  treated  early,  it  is  generally  readily  cured.  You  should 
paint  the  gums  twice  dailj^  with  a  mixture  of  half  a  drachm  to  one 
drachm  of  muriatic  acid  and  an  ounce  of  honey ;  internally  administer 
mineral  acids  in  dose  and  form  suited  to  the  age,  and  order  a  light, 
easily-digested  diet.  If  this  treatment  be  conscientiously  followed, 
the  disease  soon  disappears.  General  endemic  scorbutus  is  difficult  to 
cure,  because  it  is  generally  impossible  to  withdraw  the  patients  from 
the  injurious  endemic  influences.  In  this  also  the  acid  treatment  is 
greatly  recommended. 

4.  Syjyhilitic  ulcers.  The  marks  that  are  usually  given,  as  particu- 
larly^ characteristic  of  syphilitic  ulcers,  refer  almost  exclusively  to  the 
primary  chancre,  especially  the  soft  chancre.  This  begins  as  a  ves- 
icle or  pustule,  develops  to  an  ulcer  as  large  as  a  pea,  wdth  red  bor- 
ders and  a  yellow,  fatty-looking  base.  The  ulcer  of  the  indurated 
chancre  looks  differently ;  in  this  there  is  first  a  nodule  in  the  mem- 
brane of  the  glans  or  prepuce.  This  nodule  ulcerates  from  the  sur- 
face, as  other  cutaneous  ulcers  do.  It  usually  assumes  an  atonic, 
torpid  character,  frequently  with  a  marked  tendency  to  breaking  do\vn 
of  the  tissue.  Broad  condylomata,  one  of  the  milder  evidences  of 
constitutional  syphilis,  are,  strictly  speaking,  nothing  but  small,  su* 
perficial,   very  circumscribed  fungous  cutaneous  ulcers,  which  occur 


SYPHILITIC  ULCERS.  493 

nv'st  frequently  on  the  perinEeum,  about  tlie  anus,  and  on  the  tongue. 
The  so-called  tertiary  syphilitic  ulcers  of  the  skin  often  have  very  in- 
durated, brownish-red  borders,  are  circular,  or  horseshoe-shaped,  and 
are  also  atonic  in  character.  You  will  see  from  this  that  the  appear- 
ance of  S}^hilitic  ulcers  also  may  vary  greatly,  and  hence  that  the 
mere  appearance  of  the  ulcer  does  not  enable  us  to  judge  with  cer- 
tainty of  the  presence  of  constitutional  sj^hilis.  The  treatment 
of  true  syphilitic  ulcers  should  be  chiefly  internal,  and  be  directed 
against  the  constitutional  disease.  Locally  Ave  should  use  intense 
caustics  if  thp  destruction  of  tissue  is  going  on  rapidly. 


Older  siu"geons  also  distinguished  numerous  fonns  of  ulcers  that 
nave  not  been  mentioned  here,  and  that  were  said  to  be  characteristic 
of  the  causes.  For  instance,  in  his  treatise  on  ulcers  (Helkologie) 
Faist  speaks  of  rheumatic,  arthritic,  hasmorrhoidal,  menstrual,  abdom- 
inal, herpetic,  etc.,  ulcers.  But  I,  in  common  with  other  surgeons  of 
modem  times,  have  been  unable  to  penetrate  into  the  mysteries  of 
this  exact  diagnosis.  It  is  now  generally  considered  that  the  old  no- 
menclature was  based  rather  on  an  artificial  system  originating  in  the 
old  humoral  pathology  than  on  critically  exact  observation.  From 
unprejudiced  observation  we  should  unquestionably  acknowledge  that 
certain  forms  of  ulcers,  particularly  when  affecting  certain  localities, 
enable  us  to  decide  on  their  cause;  nevertheless,  the  appearance  and 
form  of  the  ulcer  are  very  dependent  on  the  anatomical  relations  of 
the  part  affected  (e.  g.,  as  by  the  course  of  the  filaments  in  the  skin, 
'Wertheiin)^  and  on  various  external  causes,  so  that  we  should  fre- 
quently be  deceived  if  we  rehed  too  much  on  the  appearance  of  the 
ulcer  as  an  unmistakable  expression  of  a  specific  constitutional  cause. 

[A  mode  of  treating  ulcers  of  the  leg,  uniting  moist  warmth  and. 
compression,  is  by  the  so-called  Martiii's  bandage  of  thin  rubber, 
which  is  applied  directl}'  over  the  carefullycleansed  ulcerated  sur- 
face merely  tight  enough  to  compress  but  not  to  be  painful.  This 
may  be  put  on  in  the  morning  before  rising,  the  patients  being 
allowed  to  go  around  under  this  dressing  ;  the  callous  infiltration 
gradually  softens,  and  perhaps  contact  with  the  rubber  may  have 
some  good  influence.  At  night  the  bandage  is  removed,  and  some 
simple  salve  or  moist  warmth  applied.  Massage  is  another  remedy, 
not  yet  much  used,  which  has  proved  useful  where  there  was  hard, 
callous,  immovable  skin  about  old  ulcers  ;  but  this  must  be  tried 
very  persistently. 

In  some  cases  where  the  ulcer  cannot  be  cured,  constantly  Avear- 
ing  a  rubber  bandage,  or  elastic  stocking,  enables  the  patient  to 


494  ULCERS. 

work  and  be  comfortable.  As  the  results  of  amputation  become 
more  favorable,  it  is  very  likely  that  chronic  ulcers  of  the  leg  will 
more  frequently  be  regarded  as  indications  for  amputation  than  has 
been  the  case. 

In  liqyous  ulcers,  simple  cauterization  is  far  surjDassed  by  scraping 
sus])icious  spots  ;  the  diseased  part  comes  away  readily,  Avhile  the 
healthy  tissue  resists  the  scoop  ;  after  scraping,  the  base  should  be 
cauterized. 

Another  operative  treatment  for  luj^us  is  by  making  small  in- 
cisions through  the  infiltrated  skin  with  a  lance-shaped  knife  ;  the 
bleeding  is  considerable  ;  when  it  has  been  arrested,  apply  moist 
compresses.  Sometimes  this  requires  repetition  at  intervals.  It  is 
said  that  the  resulting  cicatrices  are  less  perceptible  than  those 
from  scraping  and  cauterization.] 


CHAPTER  XYI. 

CHEONIC  INFLAMMATION  OF  THE  PEEIOSTEUM, 
OF  THE  BONE,  AND  NE  CEO  SIS. 


LECTURE   XXXII. 

Chronic  Periostitis  and  Caries  Superficialis. — Symptoms. — CsteopLytes. — Osteoplastic, 
Suppurative  Forms. — Anatomy  of  Caries. — Etiology. — Diagnosis. — Combination 
of  Various  Forms. 

Gentleiiek  :  Chronic  inflammations  of  the  bones  and  periosteum, 
to  which  we  now  pass,  are  far  more  frequent  than  the  acute  forms; 
the  more  common  disease  is  chronic  periostitis,  which  is  often  accom- 
panied by  ostitis  (caries)  superficialis.  In  the  early  stages  this  may 
end  in  resolution,  then  go  on  to  suppuration,  with  ulceration  of  the 
surface  of  the  bone ;  it  may  also  be  accompanied  by  a  deposit  of 
newly-formed  ossific  substance  on  the  surface  of  the  bone.  Perios- 
titis that  has  lasted  some  time  will  never  leave  the  bone  unaffected. 
Let  us  first  consider  the  symptoms  of  chronic  periostitis.  The  first 
symptoms  are  usually  slight  pain,  and  moderate  swelling  of  the  parts 
immediately  around  the  afi"ected  bone.  These  are  accompanied  by 
slight  functional  disturbances,  especially  when  the  disease  is  in  one 
of  the  extremities.  Spontaneous  pain  is  usually  slight,  or  may  even 
be  entirely  wanting.  Pressure  induces  severe  pain,  and  we  find  that 
the  impress  of  the  finger  remains  evident  on  the  skin  for  some  time, 
showing  that  the  swelling  of  the  skin  is  chiefly  oedematous.  The  dis- 
ease may  remain  for  a  long  time  in  this  stage,  and  may  subside  as 
gradually  as  it  began.  In  such  cases  you  may  consider  the  affection 
as  located  in  the  external  loose  connective  tissue  of  the  periosteum. 
Here  there  is  distention  of  the  vessels,  serous  and  plastic  infiltration. 

The  symptoms  above  given  may  also  depend  on  a  periostitis  com- 
bined with  a  superficial  ostitis,  only  in  the  latter  case  the  spontaneous 
pains  are  occasionally  more  intense ;  there  are  also  severe,  boring, 


496 


PERIOSTITIS. 


tearino-  pains  at  night.  If  such  a  process  has  lasted  for  months  and 
then  recedes,  the  affected  bone  remains  thickened  and  nodular  on  the 
surface.  If  you  have  a  chance  to  examine  such  a  case  anatomically, 
you  find  the  following :  The  two  layers  of  the  periosteum  cannot  be 
exactly  separated  ;  both  have  changed  to  a  fatty-looking,  tolerably- 
consistent  mass.  On  microscopical  examination  you  find  that  the  tis- 
sue consists  of  connective  tissue  richly  strewn  with  cells  and  traversed 
by  dilated  capillaries  in  greater  or  less  number.  This  morbidly-thick- 
ened periosteum  is  more  readily  detached  from  the  surface  of  the  bone 
than  is  normally  the  case  ;  the  subjacent  bone  (we  are  supposing  a 
hollow  bone,  such  as  the  tibia)  has  its  surface  covered  with  small 
nodules  of  peculiar,  occasionally  stalactite  shape.  If  you  now  saw 
through  the  bone,  you  find  that  these  nodules  on  the  still-distinct  sur- 
face of  the  compact  cortical  substance  are  a  thick  laj^er  of  porous, 
apparently  young,  newly-formed  bone-substance,  which  are  very  inti- 
mately connected  with  the  cortical  substance,  it  is  true,  but  which, 
nevertheless,  if  the  process  be  not  too  old,  may  be  broken  off  Avith  a 
chisel  in  good-sized  pieces.  If  the  disease  has  already  lasted  some 
time,  and  the  union  has  become  ver}'^  intimate,  we  find  that  the  de- 
posited porous  bone  has  become  more  compact,  especially  if  the  mor- 
bid process  has  actually  terminated. 

Let  us  stop  here  a  moment  to  inquire  the  origin  of  this  newly- 
formed  bone.  It  may  come  either  from  the  inner  surface  of  the 
periosteum,  or  from  the  surface  of  the  bone.  The  former  is  the  gen- 
erally-received opinion,  and  it  is  supposed  to  be  a  renewal  of  the 
function  of  the  periosteum,  as  it  existed  before  the  bone  had  com- 
pleted its  growth,  when  regular  layers  of  new  bone  were  always 
formed  on  the  inner  surface  of  the  periosteum.  This  form  of  perios- 
titis, which  is  combined  with  the  formation  of  osteophytes  (as  the 
young  bony  substance  deposited  during  inflammation  is  termed),  may 
be  called  osteoplastic^  a  name  which  I  shall  use,  for  the  sake  of  bre^aty. 
Nevertheless,  I  do  not  agTce  in  the  above  view,  that  osteophytes  pro- 
ceed solely  from  the  periosteum,  but  am  satisfied  that  they  actually 
grow  from  the  bone,  as  the  Greek  name  indicates.  For,  microscopic 
examination  shows  that,  in  this  case  also,  as  in  suppuration  and  gran- 
ulation on  the  surface  of  the  bone,  the  small  vessels  that  enter  and 
escape  from  the  bone  with  their  enveloping  connective  tissue  are  the 
seat  of  the  Dew  formation,  which  advances  from  the  Haversian  canals 
opening  on  the  surface  of  the  bone,  and  are  the  point  of  origin  for 
the  new  formation  of  bone,  which  then  spreads  out  under  the  perios- 
teum. These  ossifying  granulation-nodules  grow  from  within  out- 
ward somewhat  into  the  periosteum,  and  then  the  latter  takes  a 
secondary  part  in  the  process,  as  it  seems  to  me.     The  form  of  the 


CHRONIC   INFLAMMATIOX   OF  THE  PERIOSTEUM,  BONE,  ETC.   497 

osteophytes,  which  is  often  peculiar,  depends  on  the  an-angement  of 
the  vessels  around  which  the  young  osseous  material  is  deposited. 
We  would  not  by  any  means  assail  the  undoubted  fact  that  the  peri- 
osteum, and  other  parts  adjacent  to  the  bone,  may  also  produce  new 
bone,  still  I  assert  that,  correctly  viewed,  osteoplastic  periostitis  is  an 
osteoT)lastic  ostitis  superficialis.  This  subtle  distinction  has  no  prac- 
tical value,  so  far  as  we  now  know.  Osteophytes  are  the  product  oj 
an  inflammatorg  irritation  of  the  periosteum  and  surface  of  the 
bone  /  they  are  p^recisely  what  we  call  callus^  in  fractures^  and  they 
are  formed  in  the  same  loay.  I  here  remark  that  periostitis,  accom- 
panied otily  by  formation  of  osteophytes,  without  any  suppuration,  is 
especially  peculiar  to  some  forms  of  constitutional  syphilis.  The 
dolores  osteocopi,  which  may  be  so  torturing  in  the  head  and  shin- 
bones,  in  tertiary  sj^hilis,  are  almost  always  due  to  osteoplastic 
periostitis  and  ostitis. 

According  to  my  experience,  almost  every  chronic  periostitis  is  at 
first  osteoplastic  ;  all  other  terminations  follow  it  more  or  less  closely. 
The  suppurative  form  is  also  very  frequent ;  it  may  run  its  course 
without  the  bone  being  much  affected.  Recall  the  symptoms  already 
mentioned  :  oedematous  swelling  of  the  skin,  pain  on  deep  pressure, 
and  a  slight  amount  of  it  on  moving  the  limb.  This  condition  re 
mains  long  the  same,  but  is  gradually  followed  by  more  swelling,  by 
an  immovable,  doughy  tumor,  not  perfectly  but  still  tolerably  well 
defined.  By  degrees  the  skin  reddens,  and  the  tumor  fluctuates  de- 
cidedly. Four  to  six  months  may  thus  pass,  and  then  the  tumor 
remains  for  a  long  time  unchanged.  The  pain  has  probably  increased, 
and  the  function  is  more  disturbed.  If  the  disease  be  left  to  itself, 
the  cold  abscess,  which  now  evidently  exists,  will  open,  and  a  thin  pus 
mixed  Avith  flocculi  or  cheesy  substance  will  escape.  If,  through  the 
fine  opening,  3'ou  pass  a  probe,  it  will  enter  a  cavity  lined  with  gran- 
ulations. If  you  do  not  wait  for  the  spontaneous  opening  of  the 
abscess,  but  make  an  incision  through  the  thin  skin,  it  is  possible  that 
no  pus  may  escape,  but  that  you  will  find  the  fluctuating  tumor  to 
consist  of  a  gelatinous  mass  of  red  granulations  ;  in  other  cases  there 
is  some  pus  in  the  centre  of  the  swelling ;  in  still  others  the  entire 
tumor  is  of  pus.  From  what  I  have  already  told  you  of  the  anatom- 
ical conditions  in  chronic  inflammation,  you  will  readily  understand 
these  difi'erent  states.  If,  in  the  periosteum,  infiltrated  with  serum 
and  plasm,  you  imagine  a  rich  development  of  vessels,  and  at  the 
same  time  an  infiltration  of  wandering  cells,  and  transformation  of  the 
connective  tissue  to  a  gelatinous  intercellular  substance,  the  former  is 
metamorphosed  to  a  spongy  mass  of  granulations.  Tliis  may  sooner 
•or  later  change  to  pus,  and  an  abscess  is  the  final  result.  If  tlic  whole 
33 


498 


PERIOSTITIS. 


Fig.  74, 


process  affects  only  the  periosteum  and  superjacent  soft  parts,  the 
bone  is  but  little  changed  ;  some  inclination  to  new  formation  is  ei;- 
hibited  on  its  surface  by  the  production 
of  a  layer  of  osteophytes  under  and  in 
the  periphery  of  the  part  affected  with 
periostitis.  Nevertheless,  there  is  a 
possibility  of  the  abscess  healing  slow- 
ly, after  the  pus  has  been  evacuated, 
and  of  a  return  to  the  previous  normal 
state.  Such  a  recovery  of  periostitis, 
without  implication  of  the  bone,  occa- 
sionally occurs  in  practice,  but  it  is  rare. 
It  is  far  more  common  for  the  bone  to 
be  also  affected,  perhaps  only  super- 
ficially; that  is,  for  periostitis  to  be 
accompanied  by  ostitis  ;  not  an  ossify- 
ing, but  a  chronic,  suppurati\^e,  ulcer- 
ative ostitis  —  a  caries  superficialis. 
Before  the  abscess  has  opened,  the 
symptoms  of  such  a  caries  scarcely  dif- 
fer from  those  of  suppm-ative  perios- 
titis. If  the  abscess  has  opened,  we 
may  pass  a  probe  into  the  surface  of 
the  bone,  which  we  feel  to  be  rough 
and  gnawed.  The  caries  had  existed 
some  time,  and  was  secretly  eating  into 
the  bone  before  the  abscess  opened; 
it  probably  existed  when  the  perios- 
teum only  appeared  infiltrated,  and 
was  still  in  the  stage  of  gelatinous 
granulation.  Hence,  suppuration  is 
not  necessarily  combined  with  caries, 
although  it  frequently  accompanies  it. 
To  make  all  this  clear  to  us,  we  must 
study  chronic  ostitis  by  means  of  prep- 
arations. The  whole  development  and  course  are  quite  analogous  to 
the  course  of  chronic  inflammation  in  the  soft  parts,  but  the  hardness 
and  difficult,  solubility  of  bone  give  rise  to  somewhat  different  circum- 
Biances. 


Caries  superficialis  of  tne  tibia,  accnrd- 
ing  to  Follin. 


In  the  course  of  these  lectures  we  have  repeated  time  and  time 
again  that  inflammatory  neoplasia  is  developed  in  and  from  the 
affected  tissue ;  that  the  dose  connective-tissue  filaments,  by  rich  in* 


CHRONIC  INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC.   499 

filtration  of  cells,  are  transformed  into  gelatinous  or  even  fluid  inter- 
cellular substance.  Now,  how  shall  this  be  transformed  into  bone  ? 
The  cells  embedded  in  the  stellate  bone-corpuscles  participate  no  more 
in  the  inflammatory  new  formation  than  the  stable  connective-tissue 
corpuscles.  Here  also,  as  in  most  tissues  of  the  body,  the  inflamma- 
tory neoplasia  infiltrates  the  connective  tissue ;  namely,  that  which 
envelops  the  vessels  in  the  Haversian  canals,  and  in  the  medulla  of  the 
bone.  Still,  the  space  for  the  extensive  production  of  cells  is  limited, 
and,  if  the  wandering  of  the  cells  went  on  very  rapidly,  the  vessel 
would  soon  be  entirely  compressed  in  the  bony  canal ;  if  the  circula- 
tion be  then  arrested,  the  nutrition  of  the  young  brood  of  cells  also 
ceases,  and  the  necessary  result  is  death  of  the  afi'ected  portion  of 
bone  (necrosis).  Quite  right,  this  may  be  the  course  ;  superficial  ne- 
crosis may  thus  combine  with  periostitis  ;  of  this  hereafter.  Usually, 
however,  the  cell  infiltration  in  the  Haversian  canals  is  not  so  rapid  as 
to  compress  the  vessels.  The  process  is  chronic  ;  the  bone  gradually 
gives  way,  the  Haversian  canals  become  wider  and  wider,  the  firm 
cortical  substance  of  the  bone  becomes  porous,  in  the  canals  (widened 
to  meshes)  lies  the  brood  of  young  cells,  interspersed  with  gelatinous 
intercellular  substance  and  numerous  vessels,  an  interstitial  prolifera- 
tion of  granulations.  If  you  imagine  the  process  as  continuing,  the 
bone  disappears  more  and  more,  the  entire  infiltrated  portion  may  be 
dissolved,  and  the  inflammatory  neoplasm  takes  its  place.  If  you 
macerate  such  a  bone,  at  the  seat  of  disease  you  will  find  a  loss  of 
substance,  with  rough  porous  walls,  that  look  as  if  gnawed  ofi^ ;  in  this 
defect  lies  the  neoplasia  that  has  taken  the  place  of  the  bone  (Fig, 
74).  Now,  remember  that  so  far  the  word  pus  has  not  been  men- 
tioned ;  still,  of  course,  the  inflammatory  neoplasia  may  subsequently 
suppurate,  and,  if  we  continue  our  supposition  that  the  process  began 
in  the  periosteum,  you  have  a  superficial  cold  abscess  lying  on  the 
bone ;  its  walls  may  be  covered  with  granulations. 

If  you  have  carefully  followed  me  thus  far,  you  will  have  remarked 
already  that  throughout  the  whole  process  the  bone  substance  remains 
entirely  passive ;  it  is  entirely  consumed,  and  we  might  say,  with  a 
certain  amount  of  truth,  chronic  ostitis,  or  caries,  is  actually  only  a 
chronic  inflammation  of  the  connective  tissue  in  the  bone,  with  con- 
sumption of  the  latter.  And  according  to  my  view  this  is  perfectly 
correct,  at  least  for  the  great  majority  of  cases.  Still,  how  does  this 
consumption  of  bone  take  place  ?  Should  not  microscopical  examina- 
tion show  whether  the  bone-cells  are  changed  or  not  during  the  pro- 
cess ?  Remove  with  the  forceps  a  particle  of  bone,  as  thin  a  sheet  as 
possible,  from  a  carious  spot,  and  look  at  it  under  the  microscope, 
you  will  in  many  cases  see  its  edges  and  surface  bitten  out,  as  it  were  ; 


500 


CARIES. 


the  bone-corpuscles  are  unchanged ;  the  intercelluhir  substance  some- 
what more  cloudy  than  usual,  perhaps,  but  not  much  altered ;  a  sec- 
tion of  bone,  taken  from  the  vicinity  of  such  a  carious  spot,  shows 
nothing  diiferent.  If  you  saw  or  cut  out  a  piece  from  a  carious  spot, 
and  abstract  the  chalky  salts  from  the  bone  by  chromic  acid,  and  then 
make  sections  through  it  and  clear  them  with  glycerine,  you  will  have 
about  the  following  picture  (Fig.  75) ; 


Fig.  75. 


Section  of  a  piece  of  carlons  txyne  (caries  fungot^a).    Maguiflcd  350  diameters. 


These  pieces  of  bone  are  often  bitten  out,  as  it  were,  quite  regu- 
larly along  their  edges,  the  young  neoplasia  grows  into  these  defects, 
their  further  increase  goes  hand  in  hand  with  the  dissolution  of  the 
bone  ;  the  bone-corpuscles  are  unchanged,  no  destruction  starts  from 
them,  Ave  occasionally  see  them  half  destroyed  at  the  edge  of  a  piece 
of  the  bone.  What  becomes  of  the  cells  that  were  in  them,  we  can 
hardly  say ;  they  can  no  longer  be  recognized  among  the  numerous 
yoimg  cells  of  the  inflammatory  new  formation  among  which  they 
enter  ;  it  is  possible  that,  freed  from  their  cage,  they  aid  in  increasing 
the  cell-brood  by  subdividing,  possibly  they  die  ;  at  all  events,  as  far 
as  may  be  judged  by  the  change  of  form,  they  do  not  aid  in  dissolving 


CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC.   501 

tlie  bone.  But  how  the  bone  is  dissolved  remains  an  unsolved  riddle. 
Living,  like  dead  bone,  may,  to  a  certain  extent,  be  dissolved  by  the 
interstitial  bony  granulation.  Previously,  when  speaking  of  operating 
for  pseudarthrosis  by  the  insertion  of  ivory  pegs,  I  told  you,  if  you 
will  remember  (p.  244),  that  the  ivory  pegs  became  rough  on  their 
surface,  carious ;  there  the  process  is  just  the  same,  and  this  observa- 
tion is  exceedingly  interesting  and  important  as  a  proof  that  the  bone 
itself  does  not  necessarily  have  any  thing  to  do  with  its  solution  in 
caries,  but  may  play  a  perfectly  passive  part.  To  anticipate  the  charge 
that  I  admit  only  this  variety  of  consumption  of  bone,  where  the  above 
changes  occur  on  the  surface,  I  must  add  that  I  have  already  called 
attention  to  the  fact  that  the  ivory  pegs  introduced  for  pseudarthrosis 
do  not  always  become  rough  on  the  surface,  but  might  remain  smooth 
and  still  lose  substance,  as  may  be  shown  by  weighing  them  before 
and  after  the  operation.  The  morphological  appearances  in  the  carious 
bone,  which  R.  'Volhmami  very  aptly  designates  lacunar  corrosions, 
and  which  Sowship  first  made  known,  are  now  generally  recognized 
as  correct,  although  different  views  were  formerly  held  regarding  them, 
which  you  may  find  in  the  cellular  pathology  of  Virchoxc,  and  in 
Forster''s  atlas,  if  the  subject  interests  you. 

One  point,  however,  we  must  consider.  It  would  be  very  sup- 
posable  that  the  bone-substance,  having  its  nutrition  afi"ected,  would 
begin  to  break  up  and  crumble  into  very  fine  particles,  or  powder ; 
this  would  be  especially  apt  to  occur  if  the  bone  had  previously  lost 
its  organic  substance.  It  could  even  be  shown  that  this  is  the  primary 
step  in  ulceration  of  the  bone,  or  caries,  and  those  who  regard  destruc- 
tion of  tissue  as  the  primary  step  in  ulcers  of  the  soft  parts,  and  in- 
flammatory new  formation  as  the  second,  will  also  hold  this  view  in 
regard  to  bone.  As  I  have  already  stated,  my  observations  speak 
very  decidedly  against  the  universality  of  this  view  of  ulceration,  and 
what  I  did  not  find  proven  as  regards  the  soft  parts,  I  cannot  consider 
true  as  regards  the  bones.  But  there  is  no  doubt  that  portions  of 
bone  may  crumble  ofi",  and,  when  there  is  suppurative  ostitis,  these 
small  particles  of  bone  may  be  found  in  the  pus.  This  would  be  a 
necrosis  of  the  lowest  form ;  such  a  death  of  the  particles  of  tissue 
also  occurs  in  the  soft  parts,  both  in  acute  and  chronic  inflammation  ; 
70U  will  doubtless  bear  in  mind  that  we  have  spoken  of  this  subject. 
It  cannot  be  considered  as  a  rule  in  caries  ;  it  is  only  seen  occasionall}^ 
in  caries  with  suppuration  or  caseous  degeneration.  Here  even  large 
portions  of  bone  may  become  actually  necrosed,  and  for  this  combi- 
nation of  caries  and  necrosis  we  have  the  curious  name  of  caries 
nccrotica. 

Thus  far  we  have  used  the  term  caries  as  exactly  synonymous  with 


502  CARIES. 

chronic  ostitis  and  solution  of  bone,  and  at  present  this  is  very  gener- 
ally done ;  but  formerly  the  name  caries  was  only  used  for  ulceration 
accompanied  by  suppuration,  for  open  ulcers  of  the  bones.  The  inti- 
mate connection  between  chronic  inflammation  and  ulceration,  which 
we  previously  studied  in  the  soft  parts,  also  exists  between  chronic 
ostitis  and  caries.  If  you  desire  to  designate  the  character  of  the 
inflammation  inore  specifically,  it  may  be  done  conveniently  by  certain 
additions  which  you  already  know  from  the  chapter  on  ulcers.  Per- 
haps it  would  be  better  to  gradually  drop  the  name  caries  and  replace 
it  by  ostitis  with  various  additions,  such  as  rarefying,  osteoplastic, 
ulcerating,  granular,  etc.,  or  only  to  employ  caries  for  bony  defects 
caused  by  lacunar  erosions.  On  macerated  bones  this  is  always  readi- 
ly recognized;  there  we  are  never  in  doubt  as  to  whether  the  bone  is 
carious,  for  we  call  carious  all  defects  that  look  as  if  gnawed  out ; 
they  might  very  well  be  termed  lacunar  or  corrosive  defects.  But  on 
living  patients  it  requires  accurate  knowledge  and  rich  experience  to 
decide  certainly  whether  a  bone  which  a  sound  enters  readily  is  only 
softened  or  has  large  lacunar  defects.  Up  to  this  point  we  have 
only  studied  superficial  caries  ;  hereafter  we  shall  come  to  central 
caries,  which  holds  the  same  relation  to  the  superficial  that  the  ab- 
scess does  to  an  open  ulcer.  In  the  soft  parts  I  showed  you  the  de- 
velopment of  the  process  of  ulceration  in  a  fungous  ulcer,  where  the 
productive  character  predominates.  This  has  its  analog}'  in  bone,  in 
ostitis  fungosa  (by  caries  sicca,  Virchow  and  Volkmann  mean  caries 
with  proliferating  granulations  and  destruction  of  bone  without  sup- 
puration), where  there  is  as  yet  no  destruction  of  the  inflammatory 
new  formation,  but  where  interstitial  granulation-tissue  has  grown 
all  through  the  bone.  This  does  not  by  any  means  always  occur  to 
the  extent  we  have  just  supposed.  If  you  bear  in  mind  the  atonic, 
torpid  ulcer  of  the  soft  parts,  and  remember  how  the  neoplasia  rapid- 
ly breaks  down  into  pus,  undergoes  caseous  transformation,  or  disin- 
tegrates, and  simply  apply  the  same  changes  to  bone,  you  will  readi- 
ly understand  the  case  ;  this  also  gives  caries  another  character ; 
there  are  very  torpid,  atonic  forms  of  caries  where  the  neoplasia 
causes  but  little  destruction  of  bone,  and  then  disintegrates  or  under- 
goes caseous  metamorphosis,  and  thus  in  the  living  organism  there  is 
a  sort  of  maceration  of  the  diseased  bone ;  the  soft  parts  in  the  bone 
suppurate;  if  this  happen  before  the  bone  is  dissolved,  the  portion 
of  bone  that  has  suppurated  is  necrosed.  Here,  also,  most  of  the 
fault  of  the  disintegration  is  due  to  deficient  vascularity.  But  we 
must  look  to  constitutional  influences  for  the  causes  why  we  have  in 
one  case  fungous  or  proliferating,  in  another  atonic  caries. 

We  shall  become  acquainted  with  other  forms  of  ostitis  when  we 
come  to  speak  of  primary  chronic  inflammation  in  bones. 


CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC.    503 

(Chronic  inflammation  of  the  periosteum  and  bone  is  chiefly  due 
to  constitutional,  dyscrasial  diseases;  and  although  injuries,  blows, 
falls,  etc.,  may  be  exciting  causes  of  these  diseases,  the  ultimate 
cause  must  lie  in  the  injured  part  or  the  system  at  large,  otherwise 
the  process  would  take  the  course  usual  to  traumatic  inflammations 
and  soon  terminate.  If  an  injury  induces  insidious  chronic  inflam- 
mation, this  must  be  due  either  to  a  peculiar  local  or  constitutional 
condition  ;  so  far  I  have  had  no  reason  to  abandon  this  opinion. 

Of  the  dyscrasiao  already  known  to  you,  the  scrofulous  and  syph- 
ilitic especially  predispose  to  chronic  periostitis  and  ostitis  ;  among 
scrofulous  children  the  fungous  forms  of  caries  are  most  frequent, 
while  among  adults  the  atonic  occurs  oftener.  True  tubercles  are 
also  found  in  bone,  but,  so  far  as  I  know,  not  in  the  periosteum  or 
the  cortical  layer  of  the  long  bones. 

But  chronic  periostitis  also  occurs  frequently  when  none  of  the 
above  dyscrasiee  are  discoverable,  and  where  we  can  recognize  no 
cause  ;  in  old  people  especially,  periostitis  with  caries  sometimes 
comes  from  very  slight  injuries,  and  runs  its  course  in  the  most  dis- 
agreeable torpid  form. 

The  inflammatory  neoplasia  in  the  bone  will  greatly  sympathize 
if  the  general  health  fails  ;  in  children  who  have  died  of  caries,  j'ou 
will  almost  always  find  the  atonic  form,  for,  just  previous  to  death, 
while  the  nutrition  was  bad,  the  neoplasia  also  broke  down  5  the  dis- 
eased bone,  even  during  life,  was  macerated  by  suppuration  and 
mortification.  Pathological  anatomists,  who  only  see  caries  on  the 
dissecting-table,  rarely  know  the  fungous  form  accurately,  or  con- 
sider it  the  more  rare ;  but,  wdien  one  often  examines  pieces  of 
carious  bone,  cut  out  during  life,  especially  the  resected  joints  of 
children,  where  the  process  is  going  on  actively,  he  learns  to  judge 
diff'erently  from  what  he  would  in  the  anatomical  museums,  where 
macerated  bones,  almost  exclusivel}^,  are  preserved. 

Although  I  have  merely  spoken  of  fungous  and  atonic  caries, 
you  still  understand  that  I  have  only  depicted  the  extremes  of  the 
proliferating  and  rapidly  disintegrating  new  formation.  Of  course, 
there  are  many  intermediate  forms. 

It  is  not  the  object  of  these  lectures  to  carefully  delineate  all  the 
shades  of  this  process,  as  will  be  done  in  the  clinic,  but  here  the  pic- 
ture of  diseases  should  be  drawn  from  typical  cases,  yen  should  ac- 
quire a  mental  mastery  of  the  subject  ;  hence  1  only  lead  j'-ou  so  far 
into  the  details  of  the  process  as  is  necessary  for  understanding  its 
anatomy. 

Now  you  will  very  justly  ask.  How  shall  we  know  whelher  the 
case,  Avhich  we  have  only  diagnosed  with  the  probe,  be  of  the  pro- 


504  CARIES. 

liferating  or  torpid  variety  ?  Tliis  will  have  an  influence  on  the 
treatment,  as  it  has  in  case  of  ulcers  of  the  soft  parts.  And  it  is  im- 
portant not  only  for  the  treatment,  but  for  the  prognosis  ;  for  pure 
torpid  caries  oifers  far  poorer  chances  than  the  fungous  form,  be- 
cause it  is  far  more  apt  to  occur  in  poor,  badly-nourished,  and  old 
persons.  The  distinction  is  not  difficult.  In  the  more  proliferating 
forms,  the  swelling  of  the  soft  parts,  periosteum,  and  skin,  and  espe- 
cially of  the  articular  capsule  when  the  caries  afi'ects  the  articular 
ends  of  the  bone,  is  often  considerable ;  all  these  parts  feel  spongy. 
If  there  be  any  openings  in  the  skin,  proliferating  granulations  pro- 
ject from  them,  and  a  mucous,  tough,  synovia-like  pus  escapes.  If 
you  examine  with  the  probe,  you  do  not  come  at  once  on  bare  bone, 
but  must  push  the  probe  into  the  granulations,  often  to  some  depth, 
before  entering  the  rotten  bone. 

In  the  pure  atonic  form  there  is  less  swelling,  the  skin  is  thin, 
red,  and  often  undermined.  The  edges  of  the  opening  are  sharp,  as 
if  cut  out  with  a  punch ;  there  is  a  discharge  of  thin,  serous,  some- 
times badly-smelling  or  sanious  pus  ;  if  you  introduce  the  probe,  you 
come  at  once  on  the  bare,  rough  bone,  from  which  the  soft  parts  have 
already  been  separated  by  suppuration  and  maceration.  These  are  the 
extreme  cases  of  the  series ;  there  are  various  intermediate  forms. 

Taking  all  things  into  consideration,  I  think  you  will  now  have  a 
correct  idea  of  caries  superficialis. 

Let  us  make  a  short  review  of  what  we  know  of  chronic  diseases 
of  the  periosteum  and  bone.  We  have  considered  chronic  osteo- 
plastic periostitis  (with  formation  of  osteophytes  without  suppura- 
tion), suppurative  periostitis  alone,  and  combined  with  ostitis  superfi- 
cialis, or  caries.  But  osteoplastic  periostitis  may  combine  with  caries, 
and  this  combination  is  even  frequent,  i.  e.,  osteophytes  form  round  a 
carious  point  in  the  bone.  If  you  examine  a  series  of  preparations  of 
carious  joints,  you  find  the  osteophj'tes  starting  from  the  surface  of 
the  bone,  around  the  destro^'ed  portion  ;  the  periostitis,  which  at  one 
place  induced  destruction  of  the  bone,  caused  formation  of  new  bone 
in  the  vicinity.  You  may  very  aptly  compare  this  to  an  ulcer  with 
callous  edges — thickening  by  new  formation  in  the  periphery,  de- 
struction in  the  centre.  But  we  do  not  have  formation  of  osteophytes 
at  the  periphery  in  atonic  forms  of  caries ;  it  only  occurs  in  those 
which,  at  least  for  a  time,  bore  a  proliferating  character  ;  just  as  in 
torpid,  scrofulous  ulcers  you  only  find  thickened  edges  where  the  skin 
had  for  a  long  time  been  thickened  b}^  plastic  iafiltration,  so  in  the 
bone  also  we  have  this  combination  of  proliferation  and  destruction 
which  we  have  so  often  met  in  the  study  of  inflammation. 


CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC.    505 


LECTURE     XXXIIT. 

Primary  Central,  Chronic  Ostitis,  or  Caries. — Symptoms. — Ostitis  Interna  Osteoplus- 
tica,  Suppurativa,  Fungosa. — Abscess  of  Bone.— Combinations. — Ostitis  -nitii  Ca- 
seous Metamorphosis. — Tubercles  ofBoue. — Diagnosis  of  Caries. — Dislocation  of 
the  Bones  after  their  Partial  Destruction.- — Congestion  Abscesses. — Etiology. 

Hitherto  we  have  011I3'  treated  of  chronic  ostitis  in  so  far  as  it  is 
dependent  on  periostitis.  This  is  almost  always  the  case  in  the  hol- 
low bones,  for  in  them  the  cortical  layer  is  not  much  disposed  to  be- 
come primarily  diseased.  The  case  is  different  with  the  spongy  bones 
and  bony  parts  ;  in  them  a  chronic  inflammation  may  arise  indepen- 
dently, just  as  in  the  medullary  cavity  of  a  hollow  bone  there  may  oc- 
cur a  circumscribed  chronic  osteomj'elitis,  so  that  the  cortical  substance 
may  become  diseased  from  within.  These  cases  are  designated  as 
ostitis  interna  or  caries  centralis.  The  sjunptoms  of  such  a  chronic 
inflammation,  occurring  deep  in  the  bone,  are  in  many  cases  very  un- 
decided. A  dull,  moderate  pain,  and  a  consequent  slight  impairment 
of  function,  often  form  the  only  symptoms.  Swelling  comes  on  later, 
and  the  disease  may  exist  for  months  before  we  can  form  a  certain 
diagnosis.  But  when  we  find  severe  pain  on  pressure,  and  oedema  of 
the  skin,  and  the  periosteum  participates  secondarily  in  the  chronic 
inflammation,  we  shall  gradually  be  led  to  the  correct  diagnosis,  the 
more  readily  if  the  disease  be  circumscribed,  and  perforation  finally 
takes  place,  so  that  we  may  pass  a  probe  through  the  opening  deep 
into  the  bone,  and  find  exactly  what  is  the  state  of  affairs.  In  many 
cases  periostitis  is  for  a  long  time  the  chief  symptom  of  ostitis ;  the 
former  may  be  so  prominent  that  it  appears  to  be  the  only  disease, 
till,  from  the  long  duration,  and  from  losses  of  substance  from  within,  or 
lastly,  perhaps,  even  by  detachment  of  small  pieces  of  bone,  attention 
is  called  to  the  fact  that  the  continued  suppuration  is  due  to  disease 
deep  in  the  bone.  It  has  already  been  stated  that  chronic  inflamma- 
tion in  bone  first  shows  itself  by  the  chalky  salts  becoming  soluble. 
So  far  we  have  only  studied  cases  where  the  disease  was  circum- 
scribed and  progressed  inward  from  the  surface.  Now,  imagine  an 
ostitis  developing  in  a  spongy  bone,  as  one  of  the  tarsal  bones,  or  in 
the  diaphysis  of  one  of  the  long  bones,  as  in  the  lower  part  of  the 
tibia,  and  the  chalky  salts  disappearing  from  the  bony  tissue  while 
the  vessels  of  the  medulla  increase,  and  the  medulla,  infiltrated  with 
wandering  cells,  gradually  takes  the  place  of  the  disappearing  bony 
tissue.  Here  we  have  the  picture  of  a  pure  ostitis  r/iaktcissans,  an 
osteomalacia  inflammatoria  or  rarefying  ostitis  (  J^olkmann).    In  this 


506 


OSTITIS   MALACISSANS. 


affection  the  bones  become  very  light,  and  the  cortical  substance 
very  thin. 

Rindjleisch  has  shown  how  the  atrophy  occurs  in  such  cases ;  for 
he  discovered  that  the  chalky  salts  were  first  dissolved  and  disap- 
peared as  in  lacunar  corrosion.  But  while  in  the  latter  case  the 
osseous  tissue  disappeared  with  the  chalky  salts,  in  the  present  case 
the  tissue  continues  to  exist  for  a  time ;  the  cases  where  every  trace 


Fio.  75  A. 


Ostitis  malaoissans  :   n,  vertical  seetion  of  the  calcaneus,  diseased  anteriorly  and  posteriorly,  normal 
iu  tlio  middle;   b,  vercical  sectiou  of  tiie  upper  end  of  the  tibia,  quite  porous. 

of  bone  inside  the  periosteum  has  disappeared  in  this  way,  show  that 
the  osseous  tissue  which  has  lost  its  salts  is  finally  absorbed  itself. 
But  whether  this  is  always  the  case,  or  whether  it  maj'  af^ain  be  im- 
pregnated with  chalky  salts  and  again  become  normal  bone,  is  not 
known.  Whether  tliis  variety  of  atrophy,  which  may  correctly  be 
termed  halisteresis  ossium  (from  dAf,  salt,  and  OTtprjOig,  robbing, 
Killan)^  always  runs  the  course  shown  in  Fig.  76,  is  not  fully  inves- 
tigated ;  possibly  the  chalky  salts  and  the  tissue  might  be  absorbed 
at  the  same  time.  The  fact  that  there  is  no  sign  of  proliferation  in 
the  bone  corpuscles  of  tlie  tissue  deprived  of  its  chalky  salts  s  'ems 
to  pi«ovo  that  they  are  not  disposed  to  proliferate. 

So  we  have  here  a  form  of  inflammation  of  bone  in  which  its 
atrophy  is  a  particularly  prominent  feature,  and  there  is  a  very 
scanty  formation  of  osteophytes,  or  this  may  be  altogether  absent. 
In  the  bone  there  is  no  regenerative  process;  the  medulla,  which  is 


CHRONIC  IXFLAMilATIOX  OF  THE  PERIOSTEUM,  BONE,  ETC.    507 

reddened  from  the  great  vascularit\',  usually  contains  fat,  but  is 
richer  in  young  cells  than  the  medulla  of  the  bones  of  adults  usually 
is,  and  hence  more  resembles  the  condition  in  childhood.  The  ostitis 
malacissans  may  remain  in  this  state ;  should  it  slowly  progress,  it 
would  lead  to  complete  solution  of  the  bone,  till  only  medulla  and 
periosteum  remain,  and  the  bone  is  so  soft  as  to  yield  to  any  trac- 


FiG.  76. 


^1^^ 


Disappearance  of  the  chalky  salts  from  the  peripheral  portions  of  the  osseous  framework  in  ostitis 
malacissans.    Aloguiiied  350.    After  liiiidjtetack. 


tion  or  pressure ;  but  this  is  rare.  According  to  my  experience,  it  is 
just  as  rare  for  the  medulla  in  these  bones  to  suppurate  or  become 
caseous  without  some  external  cause ;  but  this  is  sometimes  induced 
by  violent  probing,  dirty  probes,  bruising,  or  operations.  Mild  cases 
of  this  form  of  ostitis  mav  recover  by  formation  of  now  bone  in  the 
cavities  of  the  old  bone ;  while  severe  cases  in  marasmic  patients  are 
incurable  and  require  amputation. 

Ostitis  osteoplastica  is  just  the  opposite  of  the  above  ;  we  do  not 
know  whether  the  disturbance  of  nutrition  by  which  it  is  started  also 
begins  with  less  of  chalky  salts  from  the  bone  ;  the  main  effect  of  the 
disturbance  is  abnormal  formation  of  new  bone  in  the  medulla  and 
in  the  Haversian  canals.  When  the  disease  occurs  in  the  long  bones, 
it  generally  attacks  the  whole  bone  at  once,  and  even  affects  several 
bones  at  the  same  time.  The  result  of  this  disease  may  be  the  com- 
plete filling  of  the  medullary  cp.vity,  with  a  tolerably  compact  bonj 


508 


SCLEROSIS   OF  BONE. 


Fia.  77. 


mass,  the  a]  most  complete  filling  of  the  Haversian  canals  with  bony  sub- 
stance, and  generally  also  the  for- 
mation of  bone  on  the  surface. 
Thus  the  entire  bone  becomes  very 
heavy  and  denser  than  normal. 
This  process  is  also  termed  diffuse 
hypertrophy  of  the  hone,  but  more 
frequently  sclerosis  ossimn  (con- 
densing ostitis,  JR.  Volkraanii). 

Besides  the  hollow  bones,  other 
bones  of  the  skeleton  are  also  oc- 
casionally attacked,  e.  g.,  bones  of 
the  face  and  pelvis ;  in  such  cases 
the  bony  deposits  are  spongy, 
puflfed,  nodular,  so  that  the  bone 
acquires  a  resemblance  to  skin  af- 
fected with  elephantiasis ;  indeed, 
the  diseases  are  very  analogous 
(Leontiasis  ossium,  Yirchow). 
The  filling  up  of  the  diploe  be- 
tween the  outer  and  inner  tables 
of  the  cranial  bones  with  bony 
substance  is  such  a  common 
change  with  advancing  age,  that 
it  can  hardly  be  considered  as 
pathological,  although  it  really 
belongs  under  this  head. 

The  causes  of  sclerosis  of  bone 
as  a  primary  disease  are  entirely 
obscure;  in  some  cases  syphilis 
may  act  as  a  cause,  but  the  osseous 
formations  occurring  in  this  dis- 
ease rarely  attain  such  firmness 
as  in  sclerosis  proper.  The  mal- 
ady will  rarely  be  recognized  with    Sclerosed    tibia  and  femur;   the  former  after 

...       T      .  -,.-       ,  i^b/^m,  the  latter  from  a  spociiuou  out  of  the 

certamty  durmg  lite,    because    to        Vienna  Pathological  Anatomical  CoUection. 

the  touch    these  bones    present 

nothing  more  than  a  certain  increase  of  thickness  and  a  slight  ine- 
quality of  surface. 

Ostitis  interna  suppurativa  circumscripta  usually  begins  in  a 
hollow  bone  as  osteomyelitis.  The  inflammation  gradually  extends 
to  the  inner  surface  of  the  cortical  substance,  which  is  dissolved,  as 
we  have  already  stated,  and  finally  completely  consumed  at  some 


CHRONIC   INFLAMMATION   OF  THE   PERIOSTEUM,  BONE,  ETC.   509 

point.  In  such  cases  pus  may  form  quite  early  in  the  centre  of  the 
inllammatory  new  formation,  and  subsequently  be  evacuated.  It  is 
this  disease  that  is  especially  termed  hone  abscess.  The  periosteum 
does  not  remain  unaffected ;  it  is  thickened  and  new  bony  deposits 
form  in  this  case  also  from  the  surface  of  the  bone,  which  is  not  at 
first  perforated  but  is  irritated  from  within.  The  hollow  bone  is  thus 
enlarged  externally  at  the  point  where  the  abscess  forms  in  it,  and 
gives  the  impression  of  the  bone  being  here  pressed  apart  and  in- 
flated. It  is  difficult,  indeed  often  impossible,  to  distinguish  such  a 
bone-abscess  from  a  circumscribed  osteoplastic  periostitis,  hence  we 
should  not  be  in  too  great  haste  to  operate.  This  central  caries  may 
be  accompanied  by  partial  necrosis  of  certain  portions  of  bone  on  the 
inner  surface  of  the  cortical  substance,  forming  a  caries  necrotica 
centralis.  Lastly,  we  have  the  worst  cases,  where  chronic  internal 
and  external  caries  are  accompanied  by  necrosis  and  by  suppurative 
or  osteoplastic  periostitis.  All  these  develop  in  one  and  the  same 
hollow  bone  at  the  same  time ;  abscesses  appear  at  different  points ; 
with  the  probe  we  sometimes  touch  rotten  bone,  sometimes  a  seques- 
trum ;  in  one  place  we  enter  the  medullary  cavity  of  the  bone,  in 
another  only  the  surface  appears  diseased ;  the  whole  bone  is  thick- 
ened, as  is  the  periosteum,  and  a  little  thin  pus  escapes  from  the 
fistulous  openings.  The  macerated  preparation  of  such  a  bone  has  a 
peculiar  appearance ;  the  surface  is  covered  with  very  porous  osteo- 
phytes; between  these,  here  and  there,  we  find  necrosed  portions 
which  belong  to  the  surface  of  the  bone  ;  some  openings  lead  into  the 
medullary  cavity ;  if  you  saw  through  these  bones  longitudinally,  you 
find  the  medullary  cavity  also  partly  filled  with  porous  bony  sub- 
stance ;  the  cortical  layer  has  lost  its  even  thickness,  and  it  also  is 
porous,  so  that  it  is  only  at  some  few  points  that  it  can  be  distin- 
guished from  the  osteophyte  deposits;  in  the  original  medullary 
cavity  we  find  occasional  round  holes,  and  in  some  of  these  necrosed 
portions  of  bone.  Tliese  bones  are  in  such  a  state  that  their  recovery 
cannot  usually  be  expected,  and  either  their  extirpation  or  amputa- 
tion of  the  limb  is  necessary. 

In  the  short,  spongy  bones  the  case  is  somewhat  different;  in 
them,  when  there  is  proliferating,  inflammatory  neoplasia,  solution  of 
the  bone  with  secondary  suppuration  comes  on  quite  rapidly,  although 
it  is  not  an  absolutely  necessary  result.  There  are  cases  of  ostitis  of 
the  short  spongy  bones  of  the  wrist  and  ankle,  and  especially  in  the 
epiphyses  of  the  hollow  bones,  where,  without  any  decided  swelling 
(which  is  usually  caused  by  the  resulting  periostitis),  the  bone  is  en- 
tirely dissolved  by  interstitial  granulations  growing  all  through  it, 
without  any  necessary  accompaniment  of  the  slightest  trace  of  sup- 


510       DISLOCATION   OF  BOXES  AFTER  PARTIAL   DESTRUCTION. 

puration  {ostitis  interna  fungosa).  The  result  of  sucli  a  solution  of 
bone  in  these,  or  in  other  joints,  is  that  by  muscular  traction  the  bones 
are  displaced  in  the  direction  where  the  destruction  is  most  advanced. 
And  from  this  deformity  we  may  judge  approximately  of  the  extent 
of  the  destruction.  A  short  time  since,  I  amputated  a  foot  which  was 
so  distorted  by  such  a  destruction  of  bone,  without  any  suppuration, 
on  the  inner  side  of  the  talus  and  calcaneus,  that  the  inner  border  of 
the  foot  was  greatly  drawn  ujd,  just  as  in  well-marked  congenital  club- 
foot, and  the  patient  walked  very  insecurely  on  the  outer  border  of 
the  foot.  A  good-sized  ulcer  had  also  formed  on  the  outer  edge, 
which  had  latterly  entirely  prevented  walking.  I  saw  a  similar  case 
in  the  wrist-joint:  A  girl  twenty  years  old  had  suffered  for  a  long 
time  from  pain  in  the  left  wrist,  without  swelling  of  the  soft  parts ; 
pressure  on  the  wrist  was  very  painful;  gradually,  without  any  swell- 
ing or  suppuration,  the  hand  became  very  much  abducted ;  if  the  pa- 
tient were  anaesthetized,  the  hand  could  be  returned  to  its  normal 
position,  and  then  it  was  found  that  part  of  the  wrist  had  entirely  dis- 
appeared. In  the  larger  spongy  bones,  as  the  calcaneus,  and  in  the 
epiphyses  of  the  larger  hollow  bones,  a  central  ca\aty,  or  a  bone-abscess, 
may  form,  and  this  may  be  accompanied  by  a  necrosis  centrahs.  In 
the  great  majority  of  cases,  however,  the  ostitis  is  accompanied  by  a 
purulent  periostitis ;  this  is  particularly  the  case  in  the  small  bones  of 
the  wrist  and  ankle ;  these  are  so  small  that,  when  the  periosteum  be- 
comes diseased,  the  disease  readily  extends  to  the  entire  bone  and  its 
articular  surfaces,  and  that  conversely  primary  disease  of  the  bone 
quickly  shows  its  effect  on  the  periosteum  and  articular  surfaces.  In 
these  cases  also  there  is  implication  of  the  sheaths  of  the  tendons 
and  of  the  skin,  which  is  perforated  at  various  places  by  ulceration 
from  within  outward.  In  the  hand  the  radius  and  ulna  as  well  as  the 
articular  ends  of  the  metacarpal  bones  may  also  be  implicated,  and  in 
the  foot  the  lower  ends  of  the  tibia  and  fibula,  as  well  as  the  posterior 
ends  of  the  metatarsal  bones.  The  wT-ist  and  ankle  joints  are  tlius 
swollen  out  of  shape ;  in  many  places  thin  pus  escapes  from  the 
fistulous  openings,  and  the  bones  of  these  joints  are  partly  dissolved 
and  partly  replaced  by  spongy  granulations,  or  else  are  entirely  or 
partly  necrosed.  It  is  hardly  necessary  to  tell  you  that  the  course 
of  this  form  of  primary  suppurative  ostitis  also,  in  regard  to  vital  re- 
lations, is  just  as  variable  as  that  of  chronic  periostitis,  and  that  here 
also  you  see  cases  of  a  tyjDical  atonic,  and  others  of  a  fungous 
variety,  while  there  are  a  variety  of  cases  between  these  extremes. 

I  must  particularly  mention  one  other  form  of  chronic  ostitis,  viz., 
ostitis  with  caseous  degeneration  of  the  inflammatory  neoplasia.  You 
are  already  acquainted  with  this  variety  of  chronic  inflammation ;  it 


cnROXIC  INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC.    511 


belongs  generally  to  the  atonic  forms,  with  slight  vascularization.     It 
occurs  chiefly  in  the  spongy  bones,  and  readily  combines  with  partial 

necrosis ;  in  the  cheesy  pulp  w^hich 
fills  the  cavity  in  the  bone  there 
are  almost  always  portions  of  dead 
bone  that  have  not  been  dissolved. 
The  vertebras,  the  epiphyses  of  the 
larger  hollow  bones,  and  the  cal- 
caneus, are  the  most  frequent  seat 
of  this  ostitis  interna  caseosa. 
This  form  is  only  recognizable  in  a 
few  cases  during  life ;  we  grad- 
ually arrive  at  the  diagnosis  of  os- 
titis interna,  but  can  only  deter- 
mine its  special  form  in  cases 
where  the  half-fluid  caseous  pulp 
is  evacuated  through  an  external 
opening.  Lastly,  we  must  not 
omit  to  mention  that  in  rare  cases, 
usually  in  the  vicinity  of  caseous 
deposits,  true  miliary  tubercles, 
small,  at  first  gray,  later  cheesy 
nodules,  come  in  the  spongy  sub- 
stance of  the  epiphyses  in  the  an- 
kle-bones and  vertebrae  and  induce 
solution  of  the  bone  and  partial 
necrosis.  A  diagnosis  of  this  true  bone  tuberculosis  cannot  be  cer- 
tainly made  during  life,  we  may  only  consider  it  as  probable  w^here 
there  is  marked  tubei'culosis  of  the  lungs  or  larynx. 

For  all  forms  of  ostitis,  wdiich  induce  softening  of  the  bone-sub- 
stance, jR.  Volkmann  emploj^s  the  designation  rarefying  ostitis. 

[We  have  now  described  a  series  of  chronic  processes,  which  may 
occasionally  occur  in  the  same  bone,  but  wdiose  natures  are  different. 
It  is  common  to  all  for  the  normal  bone  substance  to  be  dissolved 
and  replaced  by  a  soft,  cellular  neoplasia,  except  in  the  so-called 
sclerosis  ossium,  in  which  the  neoplastic  tissue  is  transformed  into 
compact  bone.  Some  of  these  processes  are  inflammatory,  as  fun- 
gous ostitis,  which  leads  to  intraosteal  development  of  granulations 
and  sometimes  to  abscess,  caseous  ostitis,  etc.  ;  but  in  so-called  ostitis 
malacissans  (rarefying  ostitis),  as  well  as  in  ostitis  osteoplastica,  the 
inflammatory  symptoms  are  more  obscure.  AYhile  in  the  first  there 
may  sometimes  be  suppuration,  in  the  latter  it  never  occurs.  In 
the  latter  processes  new  develoi^ment  of  vessels  seems  important 


Point  of  caseous  degeneration  in  the  spinal 
coliiian  of  a  man. 


512       DISLOCATION   OF   BOXES   AFTER  PARTIAL   DESTRUCTIOX. 

for  reabsorption  as  well  as  for  the  formation  of  new  bone.  In  rare- 
fyino-  ostitis  the  process  is  limited  to  solution  of  the  bone  by  for- 
mation of  medulla  which  is  transformed  to  fat,  while  in  ostitis  osteo- 
plastica  it  ossifies. 

In  the  forms  of  ostitis  which  destroy  the  bone  the  final  products 
which  take  the  place  of  the  bone  are  granulation-tissue  (fungus 
without  suppuration),  bone-pus,  caseous  neoplasia,  or  fat.  In  oppo- 
sition to  these  destructive  forms  stands  osteoplastic  ostitis  as  the 
sole  productive  form  ;  at  first  it  too  partly  dissolves  the  bone,  but 
soon  it  forms  new  bone,  not  only  to  replace  what  has  been  lost,  but 
even  beyond  the  normal  amount. 

Bony  tumors,  growths,  or  deposits  in  the  periosteum  will  occa- 
sionally disappear  spontaneously  or  nnder  some  simple  treatment. 
It  is  thought  by  some  that  they  are  due  either  to  gouty,  rheumatic, 
or  syphilitic  poison,  and  that  they  will  generally  be  benefited  by 
iodide  of  potassium  or  a  mild  course  of  mercury. 

In  children  with  hereditary  syphilis  we  sometimes  find  multiple 
caries  of  the  skull  circular  in  shape  and  surrounded  with  a  vascular 
network,  within  which,  without  suppuration,  the  bone  is  softened 
and  deprived  of  its  chalky  salts  ;  so  that  at  these  points  the  skull 
seems  to  be  replaced  by  a  translucent  vascular  membrane,  while 
there  is  not  a  trace  of  osteoplastic  periostitis,  or  any  considerable 
infiltration  of  the  soft  parts.  Such  a  skull  looks  as  if  several  tre- 
phine holes  had  healed  up,  but  not  with  bone. 

Scrofulous  diseases  of  bone  may  be  induced  by  slight  injuries, 
as  was  long  since  confirmed  by  clinical  observation  as  well  as  by 
expei'iment.  We  have  previously  stated  that  acute  infectious 
diseases  have  an  influence  in  developing  chronic  ostitis  ;  but  it  is 
doubtful  whether  contagion  here,  as  in  acute  infectious  osteomye- 
litis and  tuberculosis,  develops  and  spreads  by  micrococcus  vegeta- 
tion.] 


From  the  occasional  remarks  that  I  have  made  concerning  the 
diagnosis  of  chronic  periostitis  and  ostitis,  you  will  have  already 
seen  that,  after  they  have  lasted  a  certain  time,  their  recognition  is 
not  generally  difficult,  but  that  it  is  not  always  possible  to  state  the 
variety  and  extent  of  any  given  case.  There  are  two  very  impor- 
tant factors  for  the  diagnosis  in  those  cases  that  cannot  be  examined 
directly  by  the  sound,  viz.,  the  displacement  of  the  hones,  which 
must  result,  in  many  parts  of  the  body  at  least,  from  their  partial 
solution,  and  formation  of  abscesses,  which  often  accompanies  it. 


DISLOCATION   OF  BONES  AFTER   PARTIAL   DESTRUCTION.      613 

Carious  destruction  of  the  larger  hollow  bones  rarely  goes  so  deep 
as  to  cause  a  solution  of  continuity ;  where  this  might  otherwise  oc- 
cur, it  is  often  prevented  by  osteophytes  growing  on  the  outside  while 
the  destruction  goes  on  within,  so  that  the  bone  grows  thicker  at  the 
point  of  disease.  I  have  only  seen  one  case  where,  from  a  perfectly 
atonic  caries  of  the  tibia  of  an  old,  decrepit  person,  the  bone  was  at 
one  point  so  far  consumed  that  there  were  entire  loss  of  continuity 
and  spontaneous  fracture;  post-mortem,  examination  showed  that 
there  was  not  a  trace  of  osteophytes.  The  bone  in  Fig.  74  is  also 
nearly  eaten  through.  Complete  destruction  of  the  substance  of  the 
small  hollow  bones  of  the  phalanges  and  metacarpi  is  not  so  rare ;  the 
scrofulous  caries  of  these  bones  has  from  time  immemorial  been  called 
Pcedarthrocace,  or  spina  ventosa,  old  names  that  only  mean  caries  in 
the  fingers  or  toes,  with  spindle-shaped  enlargements.  Should  the 
bones  be  entirel}'  destroyed  by  the  fungous  proliferation  and  partial 
necrosis  of  the  small  diaphyses,  the  fingers  atrophy  and  are  drawn 
back  by  the  tendons  so  strongly  that  they  represent  misshaped  rudi- 
ments of  fingers. 

Displacement  of  the  spongy  bones  is  far  more  freqvient  when  they 
are  destroyed.  I  have  already  spoken  of  this  as  occurring  in  the 
wrist  and  ankle  bones,  still,  it  occm's  far  more  extensively  in  other 
bones ;  for  instance,  if  the  head  of  the  femur  and  upper  margin  of  the 
acetabulum  are  destroyed,  the  femur  is  gradually  drawn  up  in  pro- 
portion to  the  amount  of  destruction,  and  assumes  the  position  that  it 
has  in  upward  dislocation  of  the  hip.  Similar  dislocations  occur  in 
the  shoulder,  elbow,  and  knee,  though  there  they  are  less  remarkable. 
About  the  most  noticeable  are  the  dislocations  in  the  spinal  column 
after  carious  destruction  of  the  vertebrae  ;  if  one  or  more  vertebrte  be 
destroyed  by  ostitis,  the  part  of  the  spinal  column  lying  above  this 
point  has  no  firm  suppoi't,  and  must  sink ;  but,  since  the  arches  of  the 
vertebrae  and  spinous  processes  are  rarely  diseased  at  the  same  time, 
only  the  anterior  part  of  the  spinal  column  sinks  in,  and  an  anterior 
curvature  results,  and  a  consequent  posterior  projection,  a  so-called 
Pott''s  boss,  thus  named  after  the  English  surgeon,  Percival  Pott,  who 
first  accurately  described  this  disease.  In  every  anatomical  collection 
you  find  preparations  of  this,  unfortunately,  rather  common  disease. 
The  occun-ence  of  such  a  boss  is  occasionallj^  the  sole,  but  tolerably 
certain,  sign  of  caries  of  the  vertebra?. 

A  second  important  symptom  of  destruction  of  bone,  or  caries,  is 
the  suppuration  which  accompanies  many  or  most  cases.  The  pus 
collects  around  the  diseased  bone  ;  a  cold  abscess  forms  ;  the  pus  does 
not  always  remain  at  the  point  where  it  forms,  but  sometimes  sinks 
deeper,  particularly  when  it  has  displaced  the  parts  from  within  out- 
34 


514     CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  1?0NE,  ETC. 

ward  so  that  it  reaches  the  loose  connective  tissue.  The  most  fre- 
quent source  of  such  sinking  or  congestion  abscesses  is  the  above 
disease  of  the  vertebrae ;  as  this  most  generally  begins  as  cbronic 
periostitis  on  the  anterior  side  of  the  vertebrae,  so  this  is  the  most 

Fio.  79. 


DeBtruction  of  the  vertebral  colnmn  hy  mnltiple  periostitis  and  ostitis  atiterinr.    Preparauor 
I'rom  the  pathological  auatomical  collection  at  Basel. 


sommon  seat  of  the  suppuration ;  the  pus  sinks  behind  the  peritonasum, 
along  the  psoas  muscle,  and  usually  makes  its  appearance  below 
Poupart's  ligament,  and  to  the  inner  side ;  it  may  possibly,  but  more 
rarely,  take  a  different  course,  as  backward.  These  congestion  al> 
scesses  are  of  great  diagnostic  and  of  still  greater  prognostic  value ; 


CHRONIC  OSTITIS.  515 

&s  a  rule,  they  are  bad  signs ;  their  treatment,  of  wliicU  liereafter,  is 
one  of  tlie  most  difficult  points  in  surgical  therapeutics.  In  speaking 
of  the  sinking  of  pus,  it  is  meant  that,  following  the  laws  of  gravity, 
the  pus  sinks  mechanically ;  it  will  do  so  most  readily  where  there 
is  simply  loose  connective  tissue  present,  and  no  opposition  from 
fascia,  muscles,  or  bone.  But  I  must  call  your  attention  to  the 
fact  that  this  purely  mechanical  picture  is  only  partly  correct;  for 
it  is  partly  an  ulcerative  suppuration  that  progresses  in  a  certain  di- 
rection, which  is  only  slightly  influenced  by  the  pressure  of  the  pus ; 
the  abscess  enlarges  as  it  does  in  other  cases  ;  if  the  pus  reaches  a 
point  under  the  skin  of  the  thigh,  perforation  usually  results,  not  from 
the  mechanical  pressure  of  the  pus,  but  from  ulceration  from  within 
outAvard,  as  in  tlie  opening  of  other  abscesses ;  such  a  congestion  ab- 
scess may  last  one  and  a  half  to  two  years  before  opening  spontane- 
ously. 

We  come  now  to  the  etlologij  of  ostitis  and  caries  interna^  which 
we  may  treat  very  briefly,  as  the  cliief  factors  act  here  as  in  chronic 
periostitis,  or  in  chronic  inflammations  generally. 

It  is,  on  the  whole,  rare  for  injury  to  induce  ostitis  chronica ;  but 
this  may  develop  in  the  form  of  an  osteomyelitis  in  one  of  the  larger 
hollow  bones,  from  severe  concussion  and  bruising,  with  extravasation 
of  blood  in  the  medullary  cavity ;  the  same  thing  may  occur  from 
contusions  of  the  bones  of  the  wrist  or  ankle.  But  it  is  more  com- 
mon for  such  causes  to  induce  acute  disease,  such  as  acute  periostitis. 
If  suppuration  take  place  after  contusion  of  the  wrist  or  ankle,  if  the 
cartilage  be  destroyed  and  the  supjDuration  extend  to  the  bone,  we  may 
have  fungous  ostitis  of  the  small  spongy  bones,  and  their  complete 
destmction.  Even  healthy,  strong  persons  may,  from  protracted 
traumatic  inflammation  of  the  joint,  become  so  ana3mic  and  cachectic 
that  the  disease  will  not  go  on  to  its  normal  termination,  but  becomes 
chronic. 

Most  frequently  scrofula  and  syphilis  are  the  causes  of  chronic  in- 
flammation of  the  bones ;  in  scrofula,  while  the  children  are  fat  and 
well-nourished,  the  fungous  forms  predominate.  In  thin,  badly-nour- 
ished, scrofulous  children,  on  the  contrary,  ostitis  with  caseous  degen- 
eration and  other  atonic  forms  not  unfrequcntly  develop  ;  both  of  the 
latter  lead  to  partial  necrosis.  The  most  frequent  seats  of  scrofulous 
ostitis  and  periostitis  are  the  vertebras,  articular  epiphyses,  phalanges, 
and  metacarpal  bones ;  the  jaw-bones  and  large  hollow  bones  are 
rarely  afi"ected. 

In  syphilis,  ostitis  and  periostitis  osteoplastica  are  most  frequent 
in  the  tibia  and  cranium ;  caries  sicca  fungosa  also  occurs,  some- 
times primarily  in  the  diploe  of  the  skull,  sometimes  after  periostitis ; 


516     CHRONIC   INFLAMMATION    OF  THE   PERIOSTEUM,  BONE,  ETC. 

the  sternum,  palatine  process,  and  nasal  bones,  are  often  affected ;  ne- 
crosis often  follows  syphilitic  caries.  Some  recent  authors,  such  as 
R.  Volkmanyi,  represent  syphilis  of  the  bone  as  something  peculiar, 
under  the  name  of  ostitis  gummosa  ;  I  acknowledge  that  certain  com- 
binations are  particularly  frequent,  giving  rise  to  typical  pictures  of 
the  disease ;  but,  anatomically,  syphilis  in  the  bone  is  nothing  more 
than  ostitis  and  loeriostitis.  In  many  cases,  even  on  most  careful  ex- 
amination, we  are  unable  to  find  any  local  or  general  cause  for  the 
existing  caries,  and  I  consider  it  better  to  admit  this  than  to  try  with 
all  our  might  to  discover  some  dyscrasia. 


LECTURE    XXXIV. 

Process  of  Cure  in  Caries  and  Congestion  Abscesses. — Prognosis. — General  Healtn  in 
Chronic  Inflammations  of  the  Bone. — Secondary  Lymphatic  Enlargements.— 
Treatment  of  Caries  and  Congestion  Abscesses. — Resections  in  the  Continuity. 

Before  passing  to  the  treatment  of  chronic  periostitis  and  ostitis, 
we  must  add  a  few  remarks  about  the  process  of  cure  in  caries,  and 
about  the  prognosis.  The  first  will  vary  somewhat  with  the  activity 
of  the  process,  as  it  does  in  ulcers  of  the  skin.  Supposing  the  pro- 
cess of  proliferation  in  the  new  formation  to  cease,  the  interstitial 
granulation-tissue  will  gradually  shrink  together,  and  be  transformed 
into  cicatricial  tissue.  Considered  histologically,  this  process  consists 
of  the  retrogression  of  the  gelatinous  intercellular  substance  into  firm, 
filamentary  connective  tissue,  while  the  richly-developed  capillary 
vessels  are  mostly  obhterated,  and  the  cells  acquire  the  character  of 
connective-tissue  cells.  If  the  caries  was  accompanied  by  suppura- 
tion, the  latter  gradually  ceases,  and  the  fistulas  close.  If  part  of  the 
bone  had  already  been  destroj'cd  by  the  ostitis,  and  there  was  dis- 
placement, it  does  not  disappear,  but  the  loss  of  bone  is  supplied  by  a 
retracted  connective-tissue  cicatrix,  and  the  dislocated  bones  are  united 
in  their  false  position  by  such  a  cicatrix ;  this  connective  tissue  gener- 
ally ossifies  subsequently.  The  cicatricial  union  of  two  dislocated  bones, 
as  of  two  vertebrae,  which  have  come  into  contact  by  the  destruction  of 
a  vertebra  previously  Ijdng  between  them,  also  ossifies,  and  thus 
unites  the  vertebrge  firmly ;  the  actual  substitution  of  bone  for  any 
neoplasia  to  such  an  extent  as  to  straighten  the  spine  again,  or  en- 
tirely or  partly  to  replace  any  other  bone,  never  occurs  in  caries. 

Should  an  atonic  ulcer  of  the  bone  heal,  it  may  do  so  in  one  of 
two  ways:  either  any  poj-tion  of  bone  that  has  become  necrosed  must 


PROCESS   OF   CURE   IN  CARIES.  517 

be  detached  aud  thrown  off,  then  by  a  rich  development  of  vessels,  a 
vigorous  new  formation  must  form  from  the  walls  of  the  defect,  and 
when  there  has  been  a  large  excavation  or  abscess  in  the  bone  the 
entire  cavity  must  be  filled  with  granulations  before  recovery  is  pos- 
sible— for  a  perfect  cure  these  granulations  must  cicatrize  and  ossify, 
and  to  a  certain  extent  the  torpid  ulcer  in  the  bone  must  become  pro- 
liferating— or  else  granulations  arising  from  the  healthy  bone  behind 
the  diseased,  necrosed  portion  dissolve  the  latter ;  at  the  same  time 
the  torpid  process  becomes  proliferating,  and  thus  leads  to  cicatriza- 
tion. The  defects  in  bones,  for  example,  in  the  centre  of  a  hollow  bone, 
cannot  decrease  by  contraction,  which  so  much  curtails  healing  in  the 
soft  parts,  but  must  be  entirely  filled  up  by  new  tissue.  This  is  the 
point  that  so  often  prevents  recovery  in  caries,  for  the  constitutional 
conditions  at  the  root  of  the  torpid  form  of  caries  are  often  so  serious 
that  it  is  not  only  difficult  to  arrest  the  advance  of  the  ulceration,  but 
is  just  as  difficult  to  induce  active  new  formation  in  the  seat  of  disease. 
If  we  actually  succeed  in  arresting  the  process  of  ulceration,  fistulas 
not  unfrequently  remain  and  continue  for  years,  or  never  heal.  Never- 
theless, when  the  disease  remains  stationary,  the  fistulte  in  the  bone 
rarely  do  much  harm.  If  you  have  a  chance  to  examine  such  fistulee 
anatomically  in  macerated  bones,  you  will  find  that  the  holes  leading 
into  the  bone  are  lined  by  an  unusually  thick,  sclerosed  layer  of  bone, . 
just  like  old  fistulre  of  the  soft  parts,  whose  walls  consist  of  a  hard 
cicatricial  substance.  We  have  still  to  speak  of  the  process  of  cure  of 
chronic  cold  abscesses  in  certain  diseases;  usually,  if  not  opened, 
these  do  not  heal  till  the  bone-disease  is  on  the  way  to  recovery. 
Then,  if  the  cavity  of  the  abscess  be  lined  with  vigorous  granulations, 
as  is  rarely  the  case,  the  walls  may  unite  immediately ;  but  more  fre- 
quently, when  such  an  abscess  ceases  to  increase,  it  is  first  contracted 
by  shrinkage  of  its  inner  walls,  and  is  thus  gradually  closed.  For 
this  to  occur  it  is  requisite  that  the  process  of  destruction  should 
have  ceased  on  the  inner  wall,  and  that  the  tissue  should  be  suf- 
ficiently vascular.  If  a  cold  abscess  do  not  open,  but  remain  subcu- 
taneous, while  the  bone-disease  recovers,  most  frequently  a  large  part 
of  the  pus,  whose  cells  disintegrate  into  fine  molecules,  is  absorbed, 
while  the  inner  walls  of  the  abscess  change  to  a  cicatricial  tissue, 
which,  in  the  shape  of  a  fibrous  sac,  contains  the  puriform  fluids.  Such 
pus-sacs  often  remain  in  this  stage  for  years  ;  unfortunately,  complete 
reabsorption,  or  absorption  to  such  an  extent  as  to  leave  only  a  cheesy 
pulp,  is  much  rarer  than  might  be  desired,  and  than  is  usually  sup- 
posed. 

In  the  prognosis  of  a  case  of  caries,  we  have  first  to  consider  sepa- 
rately the  fate  awaitir  g  the  diseased  bone,  and  the  state  of  the  gen- 


518     CHRONIC   INFLAMMATION   OF  THE   PERIOSTEUM,  BONE,  ETC. 

eral  health  induced  by  long  suppuration  of  the  bone  and  soft  parts. 
Regarding  the  fate  of  the  part  diseased  we  have  already  said  enough, 
having  on  the  one  hand  described  the  process  of  destruction  and  its 
results  on  the  parts  around,  and  on  the  other  the  mode  of  the  possible 
cure.  Here  I  shall  only  add  the  remark  that,  in  caries  of  the  vei-tebrie, 
as  -we  may  readily  see,  the  spinal  medulla  may  be  endangered,  by 
participation  in  the  suppuration,  or  by  being  so  bent,  by  the  inclina- 
tion of  the  vertebra,  that  its  function  is  destroyed ;  thus  we  may  have 
paralysis  of  the  lower  extremities,  of  the  bladder,  or  of  the  rectmn, 
from  caries  of  the  spine.  Practically,  this  is  rarer  than  might  have 
been  expected  a  priori,  because  the  spinal  medulla  is  considerably 
protected  by  the  hard  dura  mater,  and  bears  quite  an  amount  of  grad- 
vial  curvature  without  impairment  of  its  function.  The  state  of  the 
general  health,  the  grade  and  variety  of  the  febrile  reaction,  are  of 
general  prognostic  significance.  Chronic  diseases  of  the  bone  rarely 
begin  with  fever;  indeed,  in  many  cases,  especially  when  there  is 
no  local  treatment,  and  the  consecutive  abscess  is  allowed  to  open 
spontaneously,  the  patient  escapes  fever  altogether.  But  this  per- 
fectly afebrile  course  does  not  continue ;  if  the  patient  has  remained 
free  from  fever  previous  to  the  opening  of  the  abscess,  after  this 
there  is  usually  hectic  fever,  which  is  generally  a  remittent  fever 
with  steep  curves,  i.  e.,  low  morning  and  high  evening  temperature. 
The  earlier  large  cold  abscesses  are  opened  the  sooner  the  afebrile 
passes  into  a  febrile  state,  and  not  unfrequently  there  is  an  intense, 
exhausting,  continued  remittent  fever ;  the  chronic  ulceration  then 
often  becomes  an  acute  inflammation,  with  great  tendency  to  disin- 
tegration of  the  diseased  tissue ;  after  the  thin,  flocculent,  but  not 
badly-smelling  pus  is  evacuated,  there  is  occasionally  sanious  sup- 
puration, which  may  be  only  temporary.  In  such  cases  pyaemia  may 
be  the  winding-up  of  the  whole  disease. 

It  is  difficult  to  state  the  cause  of  this  change  of  course  after  open- 
ing of  a  cold  abscess,  why  the  chronic  inflammation  should  so  quickly 
change  to  an  acute  form.  The  common  supposition  is,  that  the 
entrance  of  air  excites  severe  inflammation  in  the  walls  of  the  large 
abscess  cavity,  which  were  already  disposed  to  disintegrate,  and  that 
the  oxygen  of  the  air  is  the  especial  cause  of  the  decomposition.  Tins 
view  may  be  correct  in  many  cases,  but  it  is  not  the  air  itself  or  the 
oxygen  that  is  injurious,  nor  is  it  always  the  organic  germs  contained 
in  the  entering  air.  But  it  is  certain  tl)at  sometimes  puncture  or 
any  method  of  opening  gives  enough  irritation  to  excite  an  acute, 
spreading  inflammation  of  the  badlj^-organized  walls  of  the  abscess. 
In  many  cases  also  infectious  matters  may  be  inoculated  by  the  in- 
struments or  dressings.     [In  the  Medical  News  and  Library,  July, 


PROGNOSIS  OF  CARIES.  619 

1878,  Dr.  S.  Wl  Gross  expresses  his  belief  that  the  circulation  and 
nutrition  of  the  walls  are  disturbed  by  the  withdrawal  of  the  con- 
tents ;  more  blood  is  sent  to  the  sac,  its  surface  becomes  studded 
with  granulations  from  dilated  capillaries,  and  pyogenesis  is  in- 
creased. After  evacuation  he  recommends  compression  by  adhesive 
plaster  and  bandages,  and  keeping  the  parts  at  rest.]  The  possi- 
bility of  the  chronic  process  becoming  acute  in  this  way  justifies 
the  prognosis  that  opening  of  the  abscess  increases  the  danger. 
We  may  here  add  that  the  general  health  is  first  decidedly  affected 
by  the  suppuration  ;  caries  fungosa,  whether  running  its  course 
without  suppuration  or  with  only  a  slight  amount,  is  consequently 
less  dangerous  to  life  than  caries  atonica,  with  great  tendency  to 
suppuration  and  decomposition.  This  prognostic  point  is  also  based 
on  good  grounds,  for,  as  we  have  previously  stated,  proliferating 
inflammatory  new  formations  more  frequently  occur  under  compara- 
tively favorable  constitutional  conditions.  If  the  fungous  prolifera- 
tions break  down  quickly,  if  the  suppuration  becomes  more  profuse 
and  thinner,  it  is  a  bad  sign,  a  sign  that  the  general  health  has  also 
become  impaired. 

The  strength  is  used  up  partly  by  the  production  of  pus,  partly  by 
the  fever,  and  is  only  partly  replaced  because  reabsorption  does  not 
go  on  properly  from  the  stomach,  digestion  is  not  good ;  this  reacts 
again  on  the  local  disease,  and  thus  the  general  and  local  state  are 
most  intimately  connected.  The  smaller  the  carious  spot,  the  less 
dangerous  it  is  for  the  general  health ;  still  there  are  certain  localities 
where  it  is  more  dangerous  than  elsewhere ;  thus  suppuration  of  the 
vertebrge,  with  large  congestion  abscesses,  is  very  dangerous,  while 
caries  of  the  phalanges,  even  if  several  be  attacked,  has  little  effect 
on  the  general  health ;  there  is  great  difference  in  the  danger  to  hfe 
according  to  the  joint  and  diaphyses  attacked  ;  caries  of  the  hip,  knee, 
or  ankle,  is  far  more  dangerous  than  in  the  shoulder,  elbow,  or  wrist. 
Of  this  we  shall  speak  more  particularly  when  treating  of  diseases  of 
the  joints. 

The  age  is  also  of  great  prognostic  importance  in  caries — the 
younger  the  patient  the  better  hope  of  recovery ;  the  older  he  is,  the 
less  hope  :  in  caries  coming  after  the  fiftieth  year,  whether  a  sequent 
of  periostitis  or  primarily  as  ostitis,  the  prognosis  as  to  recovery  is 
very  doubtful,  insignificant  as  the  local  disease  may  be  at  first ;  I  do 
not  remember  ever  to  have  seen  caries  in  old  persons  so  frequently  as 
at  Zurich.  Lastly,  the  prognosis  depends  greatly  on  the  constitutional 
disease  to  which  the  caries  is  due.  Relatively,  syphilitic  caries  is  the 
most  favorable,  because  we  can  treat  s}T)hilis  the  most  successfully. 
In  well-nourished  children  scrofulous  caries  also  is  rarely  dangerous  to 


520     CHRONIC   INFLAMMATION    OF  THE  PERIOSTEUM,  BONE,  ETC. 

life,  as  the  scrofula  disappears  spontaneously,  or  after  the  use  of  proper 
remedies.  But  caries  in  atrophic  scrofulous  children  is  dangerous,  be« 
cause  such  children  easily  die  of  exhaustion.  The  prognosis  in  caries 
is  most  unfavorable  where  there  is  already  pronounced  tuberculosis ;  it 
very  rarely  recovers ;  the  pulmonary  disease  generally  advances  rapidly 
and  acute  miliary  tuberculosis  develops  in  the  serous  membranes,  and 
sooner  or  later  terminates  life. 

The  patient,  dying  slowly  from  chronic  suppuration,  gradually 
grows  more  and  more  emaciated,  pale,  and  very  anemic,  at  last 
oedema  of  the  lower  extremities  comes  on ;  he  eats  less,  and  finally, 
after  years  of  suffering,  he  dies  of  marasmus,  often  very  slowly ;  some- 
times he  sinks  to  rest  quietly ;  sometimes  struggles  for  days  with 
death.  Formerly  it  was  generally  supposed  that  death  in  these  cases 
was  solely  due  to  gradual  exhaustion  ;  but  more  careful  examinations 
have  shown  that  the  exhaustion  and  impoverishment  of  the  blood 
often  have  very  palpable  causes.  For  in  these  cases  we  often  find  the 
liver,  spleen,  and  kidneys,  in  a  state  of  fatty  or  amyloid  degeneration 
{Hyalinose,  0.  Weber),  a  variety  of  degeneration  which  consists  in  the 
deposit  in  the  substance  of  the  organ,  from  the  smaller  arteries,  of  a 
peculiar  material  characterized  by  its  lardaceous  consistence,  and  by 
its  reaction ;  on  addition  of  iodine  and  sulphuric  acid,  it  colors  partly 
deep-reddish  brown,  partly  dirty-brown  violet,  with  a  play  of  colors 
into  green  and  pale  red.  Concerning  the  nature  of  this  material  there 
are  various  views,  which  you  will  find  more  detailed  in  the  patho- 
logical anatomies.  I  shall  only  tell  you  here  that  the  above  reaction 
with  iodine  and  sulphuric  acid  is  similar  to  that  of  cholesterine,  and 
that  consequently  Melnrich  Meckel  von  Ilemsbach  believed  that  the 
fatty  substance  owed  its  reaction  to  the  large  amount  of  choles- 
terine it  contained.  Others  thought  that  this  material  was  allied  to 
amylum,  and  hence  Virehow,  who  held  this  view,  called  it  amyloid. 
Kuline  subsequently  showed  that  both  of  these  views  were  untenable. 
The  so-called  amyloid  is  a  peculiar  substance,  closely  allied  to  albu- 
men ;  it  diifers  from  albumen  particularly  by  its  insolubility  in  acids 
containing  pepsin.  From  the  mode  of  its  occurrence  this  material  is 
very  interesting  and  noteworthy ;  it  and  fibrine  are  the  only  organic 
bodies  we  know  that  pass  in  fluid  form  through  the  vessels,  and  out- 
side of  these  coagulate  firmly  in  the  living  body,  without  the  vital 
power  of  cells  appearing  necessary. 

The  saturation  of  the  liver,  spleen,  and  kidneys,  as  well  as  of  the 
walls  of  the  intestinal  arteries  and  of  the  lymphatic  glands,  Avith  fat, 
must  naturally  have  great  influence  on  the  formation  of  the  blood,  and 
finally  prevent  it  entirely ;  thus,  in  most  of  these  cases  death  is  caused 
by  disorganization   of  the  blood.      Extensive   chronic   suppurations 


TREATMENT   OF   CHRONIC   PERIOSTITIS.  521 

greatly  predispose  to  fatty  degenerations;  hence,  in  patients  with 
extensive  caries  we  should  carefully  attend  to  this  point,  though  fre- 
quently we  cannot  avert  it.  Besides  tuberculosis  and  amyloid  degen- 
eration, which  unfortunately  not  unfrequently  combine,  these  poor 
patients  are  occasionally  also  endangered  by  the  common  forms  of 
acute  and  chronic  diffuse  nephritis,  or  morbus  Brightii. 

I  will  also  mention  that,  in  chronic  inflammation  of  the  periosteum 
and  bone,  the  proximal  lymphatic  glands  often  participate  in  the  dis- 
ease. As  in  acute  inflammations  the  lymphatic  glands  are  often 
infiltrated  and  excited  to  acute  inflammation  by  material  coming  to 
them  from  the  point  of  disease,  so  in  chronic  inflammations  the  same 
thing  occurs  and  from  the  same  cause.  The  lymphatic  glands  swell 
slowly,  painlessl}'^,  but  often  enormously  in  the  course  of  months  and 
years ;  the  tissue  of  their  frame-work  thickens,  some  lymphatic  ves- 
sels are  obliterated,  while  others  increase  in  size ;  rarely  it  goes  be- 
yond this  hyperplastic  swelling ;  occasionally  there  are  small  abscesses 
and  points  of  caseous  degeneration. 


Now,  after  having  examined  chronic  periostitis  and  ostitis  from  all 
sides,  it  is  time  to  think  of  the  treatment.  In  so  doing,  after  having 
spoken  of  these  diseases  in  their  most  varied  extent  and  combination,, 
we  must  again  begin  with  simple  chronic  periostitis.  The  treatment 
should  be  at  once  general  and  local ;  in  all  cases  where  dyscrasial 
causes  are  evident,  they  should  be  chiefly  treated,  and  on  this  point  I 
refer  you  to  what  w^as  said  in  the  general  consideration  of  these  dys- 
crasiae  in  the  chapter  on  chronic  inflammation.  Therefore  in  this  place 
we  shall  chiefly  consider  local  remedies.  Rest  of  the  diseased  part  is 
the  first  and  most  general  rule  in  the  treatment  of  chronic  inflamma- 
tion of  the  bone ;  for  movement,  accidental  blows,  falls,  etc.,  may 
change  w^hat  would  have  been  a  mild,  not  injurious  course,  to  an  acute 
and  dangerous  one ;  hence,  in  most  cases  of  disease  of  the  bones  of 
the  lower  extremities  lying  quiet  is  of  the  first  necessity,  in  the  upper 
extremities  carrying  the  arm  in  a  sling.  This  rest  is  particularly  im- 
portant in  diseases  of  the  bone  near  the  joints  ;  under  siTch  circum- 
stances rest  is  often  spontaneously  resorted  to  because  motion  is  pain- 
ful. Some  forms  of  fistulous  caries  become  so  quiet  and  painless, 
when  suppuration  externally  begins,  that  motion  has  no  effect  on  the 
diseased  bone,  and  in  such  cases  moderate  motion  may  be  allowed. 

Elevation  of  the  diseased  part  is  a  good  adjuvant  to  the  treatment, 
for  it  avoids  venous  congestion.  This  mechanical  aid  to  the  escape 
of  the  blood  must  not  be  undervalued. 

Wlien  the  first  symptoms  of  chronic  periostitis  and  ostitis  begin. 


522     CHRONIC   INFLAMMATION    OF  THE  PERIGSTECJM,  BONE,  ETC. 

treatment  should  aim  at  inducing  resolution.  For  this  purpose,  power- 
ful antiphlogistic  remedies  are  of  little  use.  The  application  of 
leeches  or  cups,  the  internal  administration  of  purgatives,  the  appli- 
cation of  bladders  of  ice,  seem  to  me  only  beneficial  in  acute  exacer- 
bations of  chronic  inflammation  ;  theii'  action  is  always  very  tempo- 
rary, and  the  employment  of  local  bloodletting  and  purgatives  may 
even  prove  injurious  if  often  repeated.  The  repeated  application  of 
leeches  and  cups  proves  locally  irritant,  and  ma}-  finally  make  the  pa- 
tient antemic,  and  a  continuance  of  laxatives  exhausts  his  strength  ; 
hence  we  should  emplo}-  these  remedies  sparingly,  reserving  them  for 
the  acute  exacerbations.  Recently  Esmarch  has  very  urgently  recom- 
mended the  continued  application  of  bladders  of  ice  in  chronic  in- 
flammation. In  cases  accompanied  by  great  pain,  I  have  seen  very 
good  effect  from  this  treatment ;  in  other  cases  I  see  no  true  indica- 
tion for  their  use. 

[As  the  continued  use  of  ice  is  quite  troublesome,  we  may  employ 
in  its  place  the  apparatus  recently  devised  by  Letter,  of  Vienna,  by 
which  a  constant  stream  of  cold  water  is  passed  through  flexible, 
thin,  metal  pipes,  which  fit  close  to  the  body.  In  most  patients 
moist  warmth  <|uickh^  relieves  pain  and  local  swelling.  Another 
important  point  is  elevation  of  the  affected  part,  to  favor  the  return 
of  venous  blood,  which  is  also  aided  by  application  of  roller-band- 
ages. In  some  cases  cure  is  hastened  by  applying  elastic  bandages 
till  blood  is  driven  from  the  parts,  leaving  them  on  ten  to  twenty 
minutes,  and  repeating  this  daily.  At  first  the  pain  is  usually  se- 
vere, but  ceases  and  does  not  return  after  removal  of  the  band- 
age.] 

In  these  earlier  stages  massage  may  be  carefully  tried.  You  will 
accomplish  but  little  by  these  therapeutic  efforts  ;  you  wall  find  that 
as  long  as  adult  patients  can  tramp  around  on  their  diseased  bones, 
they  will  do  so  ;  when  you  tell  the  patient  that  it  is  not  certain  the 
disease  wall  get  well  if  he  lies  quiet  a  few  weeks,  but  that  it  will 
last  months  or  years  under  careful  treatment,  he  will  attend  to  his 
business  as  long  as  possible.  If  the  existence  of  your  patient's  fam- 
ily depends  on  his  daily  work,  his  case  is  very  hard.  It  is  just  as 
hard  to  keep  children  constantly  quiet  ;  a  grown  person  must  watch 
them  all  daj'.  This  is  impossible,  not  only  among  the  poor,  but  in 
large  families  among  those  in  moderate  circumstances.  It  is  very  easy 
to  say  the  child  must  lie  still  several  months,  except  when  it  is  careful- 
ly taken  into  the  fresh  air  in  a  wagon  or  laid  in  a  shady  part  of  the 
garden  during  fine  weather  ;  but  if  this  has  to  be  done  for  years,  it 
is  very  expensive,  for  it  requires  the  whole  time  of  a  careful  adult 
nurse.     This  daily,  hourly  care  for  securing  the  best  hygienic  and 


TREATMENT   OF   CHRONIC   PERIOSTITIS.  523 

dietetic  conditions  to  a  child  with  chronic  disease,  requires  unusual 
patience  and  intelligence.  Sacrifices  are  much  more  readily  made 
for  expensive  medicines,  or  going  to  watering-places,  to  get  the 
trouble  over  quickly.  In  such  cases  we  must  consider  the  circum- 
stances, so  as  to  secure  the  best  thing  possible  ;  we  may  order  me- 
chanical supports  to  keep  the  weight  of  the  body  off  the  bones.  I 
give  you  these  hints,  so  that  you  may  not  be  too  much  disappointed 
in  your  future  practice.  You  will  often  see  that  many  chronic  dis- 
eases which  are  not  incurable  never  are  cured,  on  account  of  some 
social  reason. 

Most  frequently,  at  the  very  commencement  of  chronic  inflam- 
mation of  the  bone,  the  resorbent  and  milder  derivative  remedies 
are  proper  :  officinal  tinctui'e  of  iodine,  ointment  of  iodide  of  pot- 
ash, mercurial  ointment  weakened  by  the  addition  of  lard,  mercurial 
plaster,  ointments  made  with  concentrated  solution  of  nitrate  of  sil- 
ver, hydropathic  dressings,  and  mild  compression-bandages.  With 
these  remedies,  and  proper  constitutional  treatment,  we  make  our 
first  attack  on  the  diseases  in  question,  if  they  are  just  commencing, 
and  occasionally  we  succeed  in  arresting  them  at  an  early  stage.  In 
the  early  stages  of  serous  and  moderately-plastic  infiltration  and 
slight  vascular  ectasia,  the  retrogressive  changes  either  occur  with- 
out leaving  a  trace  of  morbid  change,  or  perhaps  leave  a  moderate 
formation  of  osteophytes.  In  this  stage,  the  treatment  of  syphilitic 
diseases  of  the  bone  by  active  antisyphilitic  remedies  is  the  most 
successful. 

If  the  process  progresses,  and  the  caries  runs  its  course  without 
suppuration,  we  may  continue  with  the  above  remedies,  and  in  suit- 
able cases,  in  otherwise  vigorous  persons,  may  combine  with  the 
above,  derivatives  to  the  skin,  such  as  fontanelles,  the  hot-iron,  etc. 
If  the  signs  of  suppuration  begin,  and  abscesses  form,  you  may  con- 
tinue the  absorbent  remedies  for  a  time,  in  the  hope  of  even  yet  in- 
ducing reabsorption  ;  it  is  true,  this  will  not  succeed  in  most  cases, 
but  the  question  will  soon  arise  :  Shall  we  open  the  abscess,  or  wait 
for  it  to  open  ?  On  this  point  I  give  you  the  following  general  rule  : 
If  the  abscess  cotnesjrom  a  hone  on  xoJiich  an  operation  is  imjyossi- 
ble  or  undesirable  (as  the  vertebrae,  sacrum,  pelvis,  ribs,  knee-joint, 
etc.),  do  not  meddle  icith  it,  but  be  thankful  for  every  day  that  it 
remains  closed,  and  wait  quietly  till  it  opens,  for  thus  there  will  be 
relatively  the  least  danger.  When  I  have  departed  from  this  prin- 
ciple, I  have  always  regretted  it.  I  saw,  with  great  pleasure,  that 
Piriogoff  said  almost  exactly  the  same  thing.  Experience  has  suffi- 
ciently shown  that  none  of  our  operations,  aiming  at  imitating  the 
slow  spontaneous  opening  of  these  abscesses,  prove  as  little  irritat- 


524       CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC. 

ing  as  the  slow  perforation  of  the  skin  from  within  by  ulceration. 
Various  methods  have  been  proposed  for  opening  large  cold  ab- 
scesses, corresponding  to  the  theories  in  regard  to  them.  For  a 
time  it  was  thought  that  the  pus  must  escape  slowly,  in  order  to 
prevent  inflammation  of  the  abscess-walls.  To  accomplish  this,  se- 
tons  were  introduced,  and  the  pus  allowed  to  trickle  from  the  points 
of  opening.  Then  it  was  claimed  that,  besides  this  slow  escape  of 
matter,  the  skin  should  be  perforated  slowly.  For  this  purpose,  a 
caustic  was  applied  to  the  thinnest  spot  of  the  abscess,  and  a  slough 
made,  which  gradually  became  detached,  whereupon  the  pus  slowly 
escaped.  Subsequently  it  was  supposed  that  we  should  carefully 
avoid  the  entrance  of  air,  as  this  was  the  dangerous  point ;  so  a  tro- 
car was  introduced,  a  j^ortion  of  the  pus  was  evacuated  and  the 
opening  accurately  closed,  or  the  so-called  subcutaneous  puncture, 
according  to  Abernethy,  was  made,  i.  e.,  the  skin  over  the  abscess 
was  lifted  up,  and  a  narrow-bladed  knife  was  passed  under  it  into 
the  abscess,  a  large  part  of  the  pus  was  evacuated  ;  then  the  knife 
was  quickly  withdrawn,  and  the  skin  allowed  to  go  back  into  its 
original  position,  so  that  the  puncture  in  the  skin  did  not  communi- 
cate directly  with  that  in  the  abscess-sac,  but  the  latter  was  covered 
by  the  skin  ;  the  cutaneous  opening  was  carefully  closed.  Subse- 
quently great  importance  was  attached  to  placing  the  walls  of  the 
abscess  in  such  a  condition  that  the  formation  of  pus  should  cease  ; 
it  was  thought  that  this  could  be  done  by  injecting  solutions  of 
iodine  after  the  pus  was  evacuated  ;  this  method  was  especially 
popular  in  France. 

\^Lelster  and  Volhnann  propose,  after  carefully  disinfecting  the 
field  of  operation,  to  open  the  abscess  freely  by  a  long  incision,  and, 
instead  of  merely  emptying  it,  to  scrape  its  walls  and  remoA'e  the 
useless  granulations  with  a  scoop,  arrest  the  bleeding  by  ice-water 
[or  hot  water]  or  compression,  wash  the  cavity  with  a  two-per-cent. 
solution  of  carbolic  acid,  and  dry  with  clean  sjionges.  After  this, 
disinfect  with  a  six-per-cent.  solution  of  chloride  of  zinc,  which 
causes  a  slight  slough  that  prevents  absorption  of  the  products  of 
decomposition.  Now  apply  short  drainage-tubes  at  various  points, 
sew  up  the  incisions,  and  apply  a  Lister''s  dressing  and  a  good  com- 
press over  the  abscess-cavity.  By  this  treatment,  first  the  relaxed, 
inactive  granulations  forming  the  walls  of  the  abscess,  which  are  un- 
dergoing fatty  or  cheesy  degeneration,  are  removed  down  to  the 
healthy  tissue,  every  opportunity  for  stagnation  or  decomposition 
of  pus  is  diminished  to  the  lowest  point,  and  the  collection  of  more 
pus  after  the  sudden  reduction  of  pressure  is  impeded  by  compres- 
sion, which  favors  the   immediate   adhesion  of   the  Avails  of   the 


TREATMENT   OF  CnROXIC  PERIOSTITIS.  525 

abscess,  that  now  resemble  freshly-wounded  surfaces.  This  treat- 
ment, which  requires  great  accuracy  and  thoroughness,  has  excel- 
lent results. 

A  recent  improvement  on  the  above  is  the  use  of  iodoform. 
For  some  time  past,  after  scraping  the  abscess-cavity  I  have  filled 
it  with  iodoform,  tlien  unite  the  edges,  except  where  a  couple  of 
drainage-tubes  pass  out,  and  apply  a  regular  Zister^s  dressing. 
The  iodoform  prevents  decomposition  inside  the  sac,  and  inflamma- 
tory complications,  while  strong  healthy  granulations  spring  up  and 
hasten  the  cure.  The  general  state  of  patients  thus  treated  im- 
proves wonderfully,  which  is  partly  because  in  the  abscess-cavity 
there  is  no  true  pus,  but  only  a  moderate  quantity  of  sero-mucous 
secretion.  It  is  still  a  question  whether  by  the  iodoform  treatment 
we  may  perhaps  treat  successfully  those  cold  abscesses  which  are 
still  inaccessible  to  Z,ister^s  dressing.  Unfortunately,  there  are 
other  cases  which,  do  what  you  may,  will  turn  out  badly,  and, 
whether  you  have  treated  them  expectantly  or  actively,  the  public 
will  ascribe  to  you  the  lack  of  success  ;  for  the  laity  have  no  idea 
of  the  danger  of  a  cold  abscess,  and  judge  of  it  as  they  would  of  an 
acute  one.] 

Recently  a  French  surgeon  ( Chassaignac)  has  returned  with 
great  enthusiasm  to  the  old  setons  ;  but,  instead  of  these,  he  chose 
fine  tubes  of  caoutchouc  vv'ith  perforated  walls,  so  that  the  escape  of 
the  pus  was  greatly  facilitated  (Drainage,  page  109). 

[While  the  introduction  of  drainage  is  commonly  ascribed  by 
the  French  to  their  distinguished  countryman  Chassaignac,  it  is 
really  of  older  date.  It  is  said  that  Benjamin  Bell  in  the  eighteenth 
century  used  tubes  made  of  lead  for  this  purpose. 

Tubes  made  by  winding  wire  on  a  metal  rod  of  suitable  diam- 
eter placed  in  a  lathe,  so  as  to  form  a  spiral,  make  good  drainage- 
tubes  ;  they  are  flexible,  and  permit  the  entrance  of  pus  at  any  part, 
while  injections  pass  through  to  all  points  of  the  wound.] 

Lister,  an  English  surgeon,  particularly  urges  that  in  opening 
these  abscesses  the  instruments  and  dressings  should  be  previously 
disinfected  with  carbolic  acid,  and  also  that  the  entrance  of  air 
should  be  carefully  avoided  ;  his  proceeding,  like  all  previous  ones, 
has  enthusiastic  advocates.  It  is  not  easy  to  decide  on  the  value 
of  all  these  methods  ;  but,  when  such  a  number  of  remedies  and 
methods  are  recommended,  you  may  almost  always  decide  that  the 
disease  in  question  is  very  difiicult  to  cure,  and  that  none  of  the 
remedies  are  suited  for  all  cases.  Let  us  briefly  criticise  the  above 
plans  of  treatment. 

A  single  evacuation  of  the  pus  usually  has  at  first  a  tolerable 


526     CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC. 

result,  if  done  slowly  and  carefully,  whether  with  the  trocar  or  sub- 
cutaneously  with  the  knife,  with  or  without  Lister''s  carbolic-acid 
treatment.  If  the  opening  is  nicely  closed  and  heals  up,  there  is  usu- 
ally no  fever,  but  the  abscess  fills  again  very  quickly  ;  an  abscess  that 
probably  took  ten  months  to  form,  may  fill  again  in  ten  days.  This 
is  also  punctured ;  the  opening  again  closes  ;  the  patient  grows  fever- 
ish ;  the  pus  again  collects  rapidly.  A  third,  and  perhaps  a  fourth  or 
fifth,  puncture  is  made,  always  in  a  new  spot ;  the  patient  grows  more 
feverish,  the  abscess  is  hotter  and  more  painful ;  the  patient  looks 
languid  and  suffering.  Now  the  points  of  puncture  cease  to  heal,  the 
previous  ones  open  again,  there  is  a  continvial  escape  of  matter,  and 
occasionally,  in  spite  of  all  our  care,  air  enters,  especially  when  the 
walls  of  the  abscess  are  rigid  and  do  not  collapse.  Now  there  is  a 
fistula,  the  fever  is  continued,  and  the  subsequent  course  is  most  un- 
favorable, as  we  described  it  above.  So  far  as  my  experience  goes, 
the  course  is  not  much  changed  if  the  puncture  be  followed  by  injec- 
tion of  iodine.  There  is  not  much  diiference  if  you  make  the  opening 
with  a  seton,  with  drainage-tubes,  or  b}'  cauterization.  I  have  seen 
nothing  from  any  of  these  methods  that  in  the  least  approximated  the 
claims  of  their  proposers. 

It  is  true  this  unfortunate  course  may  be  run  if  you  do  nothing  to 
the  abscess  but  leave  it  to  itself  and  await  its  opening ;  but  then  all 
progresses  more  mildly  and  slowly,  and  fever  comes  on  later.  Recov'- 
eries  take  place  under  all  these  modes  of  treatment,  but  I  think  there 
are  more  recoveries,  and  certainly  fewer  deaths  from  pyaemia,  under 
the  expectant  treatment.  I  am  satisfied  that  where  recovery  has  fo?- 
lowed  injections  of  iodine,  drainage,  etc.,  it  would  also  have  occurred 
had  the  course  of  the  disease  not  been  interrupted ;  we  cannot  accept 
the  assertion  that  a  case  would  have  run  its  course  thus  and  so,  if  this 
and  that  had  not  been  done.  Summing  up  my  own  experiences,  I 
can  assure  you  that,  of  very  many  cases  of  large  congestive  abscesses 
along  the  spinal  column,  artificially  opened,  I  know  very  few  that  ran 
a  favorable  course ;  the  others  were  only  hastened  to  their  end.  Hence 
I  again  repeat  the  previous  assertion,  that  these  abscesses,  especially 
congestive  abscesses  from  caries  of  the  vertebra?,  are  a  noli  me  tangere. 
In  such  cases  it  is  indeed  frequently  very  difficult  to  Avait ;  in  private 
practice,  especially,  the  patients  become  impatient ;  the  surgeon  is  urged 
to  do  something,  it  is  cast  up  to  him  that  he  does  not  try  any  thing ; 
the  public  firmly  believes  that,  if  the  pus  was  only  out,  recovery  must 
follow.  The  surgeon  also  at  length  becomes  weary;  it  is  trying 
to  look  on  from  week  to  week  as  the  abscess  increases;  all  local 
and  constitutional  remedies  are  exhausted,  and  finally  the  surgeon 
departs  from  his  principles  and  makes  an  opening ;  at  first  all  goes 


TREATMENT   OF   BONE   ABSCESSES.  527 

well,  but  this  does  not  continue ;  you  already  know  the  subsequent 
course. 

Tlie  case  is  somewhat  diflferent  when  we  have  to  deal  with  small 
abscesses  originating  in  disease  of  hones  of  the  extremities  ;  in  suppu- 
rations connected  \Wth  the  larger  joints,  we  also  willingly  postpone 
opening ;  we  shall  speak  of  this  hereafter,  under  diseases  of  the  joints. 
In  cold  abscesses  from  the  diaphyses  delay  is  not  of  much  avail ;  here 
I  rather  consider  an  early  opening  as  proiDcr,  except  in  syphilitic 
gummata ;  in  these  cases  there  may  be  reabsorption,  even  after  there  is 
evident  fluctuation,  and  in  markedly  tuberculous  or  debilitated  persons, 
in  them  no  operative  interference  is  indicated,  and  opening  the  abscess 
would  only  induce  profuse  suppuration,  without  doing  any  good.  In 
the  other  cases  I  am  in  favor  of  opening  the  abscess  freely,  to  obtain 
a  clear  view  of  the  variety  and  extent  of  the  disease ;  under  these 
circumstances  the  reaction  is  insignificant,  frequently  there  is  no 
fever,  often  there  is  moderate  fever  for  a  short  time.  Let  us  suppose 
a  chronic  periostitis  with  caries  superficialis  of  the  diaphysis  of  a 
hollow  bone ;  an  abscess  has  formed  and  been  opened  ;  the  wound  is 
at  first  dressed  with  charpie,  and  we  then  wait  to  see  what  appear- 
ance the  surface  of  the  ulcer  will  assume.  The  local  treatment  should 
be  modified  according  as  the  ulcer  is  proliferating  or  accompanied  by 
breaking  down  of  tissue,  and  I  should  only  be  repeating,  were  I  to 
refer  again  to  the  proper  remedies.  The  treatment  may  be  aided  by 
local  baths,  Avhich  we  may  render  slightly  irritant  by  the  addition  of 
potash  or  tincture  of  iodine.  Wet  compresses,  cataplasms,  charpie- 
wads  wet  with  various  fluids,  serve  as  dressings.  The  subsequent 
course  will  show  more  and  more  to  what  extent  the  bone-disease  de- 
pends on  the  general  health.  If  the  patient  be  a  weakly,  tuberculous 
individual,  all  local  remedies  are  in  vain  ;  if  the  general  health  be 
good,  you  may  even  resort  to  energetic  local  treatment.  If  the  ulcer 
does  not  improve  under  milder  remedies,  you  may  apply  the  hot  iron  ; 
should  this  be  followed  by  formation  of  strong,  healthy  granulations, 
it  is  a  favorable  sign,  even  if  there  be  necrosis  of  the  carious  portion  of 
bone.  In  other  cases  we  abandon  all  idea  of  inducing  healing,  and  cut 
out  the  entire  affected  part.  For  this  purpose  there  are  various  forms  of 
cutting  forceps  and  saws  ;  I  prefer  detaching  the  diseased  bone  with 
scrapers,  gouges,  and  hammer,  to  all  other  methods.  If  the  ulcer  of 
the  bone  has  been  cleanly  cut  out,  and  the  general  health  be  tolerably 
good,  it  is  to  be  hoped  that  the  wound  of  the  bone  made  in  the  opera- 
tion will  heal  normally  by  healthy  granulation  and  suppuration,  as 
other  wounds  of  bone  do.  Should  the  caries  afi'ect  a  small  bone,  it 
may  be  proper  simply  to  extirpate  it,  to  arrest  the  process  at  once. 
If  the  case  be  one  of  ostitis  interna,  caries  centralis  of  a  hollow  bone, 


528     CHRONIC   INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC. 

or  of  a  large,  spongy  bone,  such  as  the  calcaneus ;  if  severe  pain  and 
other  previously-mentioned  symptoms  of  bone-abscess  gradually  ap- 
pear, it  may  become  proper  to  chisel  out  the  bone,  or  open  the  cavity 
of  the  bone  and  let  out  the  pus ;  but  I  only  advise  this  operation  when 
you  are  sure  of  your  diagnosis,  for  it  is  no  slight  injury  to  a  patient 
to  have  a  healthy  medullary  cavity  opened.  Very  acute  osteomyelitis, 
with  its  often  dangerous  results,  may  arise  from  untimely  interference, 
while  a  similar  operation  on  a  diseased  bone  is  not  usually  very  seri- 
ous. In  other  cases  you  will  await  the  spontaneous  opening  of  the 
abscess  through  the  bone ;  then  you  may  use  a  probe,  and  judge  accu- 
rately of  the  state  of  afiairs.  The  obstacles  to  the  healing  of  such 
excavations  in  the  bone  have  been  previously  mentioned ;  should  the 
process  remain  stationary  for  a  long  time,  it  may  be  best  to  enlarge 
the  opening  in  the  bone,  expose  the  abscess,  and  remove  its  walls ; 
this  will  be  the  more  necessary  if  there  are  any  small  necrosed  por- 
tions of  bone  in  the  abscess-cavity  which  prevent  its  healing  ;  that  is, 
if  the  case  be  one  of  caries  necrotica.  But  all  these  manipulations 
are  only  indicated  if  the  general  health  be  good ;  if  there  be  ad- 
vanced tuberculosis  or  marasmus,  and  the  disease  will  necessarily 
prove  fatal,  no  surgeon  would  Avish  to  do  an  operation  which  can  only 
prove  successful  when  the  local  changes  in  the  new  wound  of  the 
bone  go  on  normally.  These  operations,  part  of  which,  at  least,  may 
be  classed  among  the  partial  resections  in  the  continuity^  have  lost 
their  cruel  and  terrible  appearance  since  the  introduction  of  chloro- 
form, by  whose  aid  the  patients  escape  feeling  the  chisel,  hammer, 
and  saw. 

In  those  cases  where  the  caries  is  so  extensive  as  to  affect  the 
whole  thickness  of  a  long  bone,  we  might  think  of  sawing  out  the  en- 
tire diseased  part.  This  case  is  very  rare,  and  such  operations  are  of 
extremely  doubtful  benefit.  We  might,  it  is  true,  saw  out  a  piece  from 
the  middle  of  the  fibula,  radius,  or  ulna,  from  the  metacarpal  or  meta- 
tarsal bones,  without  greatly  impairing  the  function  of  the  extremity ; 
but,  should  we  do  the  same  for  the  humerus,  femur,  or  tibia,  and  re- 
covery take  place,  the  function  of  the  extremity  would,  at  most,  only 
be  partially  restored  by  aid  of  an  apparatus  ;  in  the  lower  extremity 
an  artificial  leg  would  be  of  more  use  than  a  leg  that  had  lost  a  con- 
siderable portion  from  the  continuity  of  the  bone.  It  has  been 
thought  that  the  periosteum,  detached  from  the  bone  before  it  is 
sawed,  and  left  in  the  wound,  would  form  new  bone ;  but  after  opera- 
tions for  caries  this  regeneration  of  bone  is  very  scanty,  so  that  we 
(unnot  count  much  on  it.  Moreover,  caries  is  the  rarest  indication  for 
these  total  resections  in  the  continuity. 

Lastly,  in  regard  to  those  cases  which  are  on  the  whole  rare,  where 


TKEATMENT   OF   BOXE   ABSCESSES.  529 

a  hollow  bone  is  diseased  throughout  with  periostitis,  external  and 
internal  caries,  partial  internal  and  external  necrosis,  there  can  only 
be  a  question  of  extirpation  of  the  entire  hone,  or  amputation  of  the 
affected  limb.  Cases  of  extirpation  of  the  entire  ulna  or  radius  oc- 
casionally turn  out  well ;  extirpations  of  the  first  metacarpal  bone  are 
often  successful.  I  also  know  of  a  case  where  the  whole  humerus 
was  removed,  leaving  behind  the  thickened  periosteum ;  but  the  pa- 
tient died  a  few  months  after  the  operation  from  some  internal  dis- 
ease, morbus  Brightii,  if  I  mistake  not,  so  that  no  decision  could  be 
made  about  the  usefulness  of  the  extremity  ;  in  spite  of  the  absence 
of  the  humerus,  the  hand  might  have  been  of  service,  which  of  itself 
would  have  been  a  great  gain  to  the  patient.  Caries  of  the  short, 
spongy  bones,  and  of  the  articular  epiphyses,  is  so  intimatply  con- 
nected with  diseases  of  the  joints  that  we  shall  discuss  it  hereafter. 

The  state  of  general  marasmus  that  finally  occurs  from  diseases 
of  the  bone,  with  extensive  suppuration,  is  to  be  treated  on  general 
principles.  We  should  try  to  prevent  its  occurrence,  or  at  least  ward 
it  off  to  the  utmost.  It  is  the  physician's  duty  to  preserve  life  as 
long  as  possible.  It  is  also  his  duty,  even  in  a  patient  almost  cer- 
tainly dying,  to  give  him  every  thing  that  can  keep  up  his  strength. 
Nourishing,  tonic,  strengthening  diet  is  to  be  given  from  the  time 
the  first  symptoms  of  emaciation  show  the  failure  of  nutrition ;  later 
it  is  of  no  use.  In  children  and  young  persons  the  inexjDerienced 
physician  may  readily  be  deceived  as  to  the  strength,  and  you  will 
hereafter  see  that  patients  in  a  very  bad  state,  emaciated  to  a  skele- 
ton, and  excessively  anasmic,  pick  up  wonderfully  and  unexpectedly 
on  amputation  of  the  diseased  hmb,  which  seemed  to  be  consuming 
their  life ;  of  course  benefit  could  rarely  result  from  resection  under 
such  circumstances.  How  far  it  is  safe  to  carry  the  principle  of  pre- 
semng  the  limb  by  sawing  out  the  diseased  portion  of  bone  can 
only  be  judged  of  in  individual  cases,  and  then  only  approximately. 


LECTURE    XXXV. 

Necrosis. — Etioloa'y. — Anatomical  Conditions  in  Total  and  Partial  Necrosis. — Symp- 
toms and  Diagnosis. — Treatment. — Sequestrotoniy. 

GEisTTLEirEN" :  We  have  already  frequently  spoken  of  "  necrosis," 

and  you  know  that  by  this  term  we  mean  gangrene  of  the  bone, 

death  of  a  bone,  or  part  of  a  bone.     I  have  also  told  you  that  the  dead 

portion  of  bone  is  called  a  sequestrum.     You  also  know  that  necrosis 

35 


530     CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC. 

may  result  either  from  an  acute  process,  or  accompany  the  process  of 
ulceration  as  "  caries  necrotica." 

As  in  death  of  any  part,  cessation  of  circulation  is  also  the  im- 
mediate cause  of  necrosis,  while  cessation  of  nervous  activity  does 
not  induce  it,  although  a  disturbance  of  nutrition,  an  atrophy  of  the 
bone,  is  occasionally  seen  in  paralyzed  parts.  Necrosis  may  be  due 
to  various  causes ;  we  shall  briefly  group  them  together : 

1.  Traumatic  influences.  Among  these  are  severe  concussions  and 
injury  of  the  bones,  even  without  external  wounds.  The  course  is  as 
follows :  As  a  result  of  the  above  injuries  there  are  extravasations 
in  the  medulla  of  the  bone,  also  into  the  spongy  bones,  perhaps  also 
in  the  compact  bony  substance,  and  occasionally  under  the  periosteum. 
If  these  ruptures  of  the  vessels  be  so  extensive  that  their  results 
cannot  be  removed  by  collateral  circulation,  which  is  of  difficult  es- 
tablishment in  bone,  part  of  the  bone  will  no  longer  contain  any 
blood ;  this  will  die,  and,  according  to  circumstances,  we  may  have 
central,  superficial,  or  total  necrosis  (the  latter  occurs  most  readily  in 
the  small  bones).  The  portion  of  dead  bone  remains  in  the  organism 
as  a  foreign  body,  but  still  continues  in  continuity  with  the  healthy 
bone ;  the  solution  of  the  sequestrum,  by  Uquefaction  of  the  bone- 
substance  in  the  border  of  the  living  tissue,  has  been  already  ex- 
plained (page  232).  Another  mode  of  injury  is  exposure  of  the  sur* 
face  of  the  bone,  or  sawing  through  a  bone,  by  which  the  sawed  sur- 
face becomes  the  surface  of  the  bone ;  in  complicated  fractures  a 
piece  of  bone  may  be  so  denuded  of  soft  parts,  and  thus  robbed  of 
its  circulation,  that  it  becomes  necrosed.  We  have  also  explained 
why  the  exposed  bone  or  sawed  surface  does  not  always  become  ne- 
crosed, but  that  the  bone  may,  like  the  soft  parts,  immediately  pro- 
duce granulations.  Nevertheless,  after  the  above  injuries,  superficial 
or  partial  necrosis  is  common  enough,  either  because  extensive  clots 
form  in  the  ends  of  the  injured  vessels  of  the  bone,  or  because  the 
vessels  are  compressed  and  suppurate  on  account  of  the  acute  su2')pu- 
ration  in  the  Haversian  canals. 

2.  Acute  periostitis^  ostitis,  and  osteomyelitis,  are  very  frequent 
causes  of  occasionally  extensive  and  especially  of  total  necrosis  of 
the  hollow  bones.  In  suppuration  of  the  periosteum  the  supply  ol 
blood  to  the  bone,  by  vessels  passing  through  the  periosteum,  is  cut 
off,  and  the  suppuration  is  propagated  through  the  Haversian  canals 
to  the  medullary  cavity ;  if  the  latter  also  suppurates,  necrosis  is  In- 
evitable, and  will  extend  as  far  as  the  inflammation  did.  The  same 
results  will  occur  in  primary  acute  ostitis  and  osteomyelitis  with  seo- 
ondary  periostitis. 

3.  Chronic  ostitis  and  periostitis  may  combine  with  necrosis,  for, 


AJSTATOMY   OF  NECEOSIS, 


531 


just  as  in  the  acute  processes,  suppuration,  change  of  the  inflamma- 
tory new  formation  to  detritus  or  caseous  matter,  extends  into  the 
bone,  and  so  impairs  its  circulation  that  part  of  the  bone  is  no  longer 
nourished  and  must  necrose ;  atonic  forms  of  caries  induce  necrosis 
more  readily  than  the  fungous  forms,  as  has  already  been  stated. 

The  necrosis  that  is  supposed  to  occur  after  thrombosis  or  embo- 
lism of  the  cliief  trunk  of  the  nutrient  artery  of  a  bone  appears  to 
be  of  more  theoretical  than  practical  importance.  This  variety  of  ne- 
crosis has  hardly  been  proved  by  dissections  on  man  ;  it  is,  moreover, 
very  improbable,  because  the  arterial  supply,  in  full-grown  bones, 
comes  from  so  many  sources  that  stopping  one  of  the  many  afferent 
branches  does  not  suffice  to  completely  arrest  the  circulation  in  any 
considerable  portion  of  bone.  Although  the  collateral  circulation  in 
bone  cannot,  from  mechanical  causes,  be  greatly  facilitated  by  dilata- 
tion of  the  vessels,  and  hence  in  capillary  stasis  there  is  always  danger 
of  partial  necrosis,  as  already  stated,  still  the  connection,  arrange- 
ment, and  regular  distribution  of  the  capillaries,  even  in  the  firm  cor- 
tical substance,  are  such  that  when  the  afflux  is  interrupted  from  one 
source  it  may  easily  come  from  another.  In  bone  there  are  no  defined 
capillary  net-works  and  capillary  groups  as  in  the  skin,  but  all  the  cap- 
illaries are  intimately  connected  in  all  directions,  as  in  the  muscles. 

The  experiment  of  inserting  a  peg  into  the  foramen  nutritium  in 
the  upper  part  of  the  tibia  of  rabbits  has  been  tried,  and  it  has  been 
followed  by  necrosis  around  the  peg.  I  have  made  this  experiment 
and  obtained  the  same  result  by  inserting  the  peg  at  any  other  part 
of  the  bone,  and  hence  I  believe  that  this  experimentally-induced  ne- 
crosis depends  only  on  the  variety  of  the  injury  to  the  bone. 

It  will  be  proper  now  to  study  more  accurately  the  anatomical 
course  of  necrosis,  especially  of  that  coming  after  acute  periostitis 
and  osteomyelitis.  I  have  already  told  you,  on  various  occasions, 
when  treating  of  the  healing  of  fractures  and  of  chronic  ostitis  and 
periostitis,  that  the  vicinity  of  such  collections  of  pus  is  almost  al- 
ways affected  in  such  a  way  that  osteophytes  form  on  and  in  the 
bone ;  their  development  is  greatly  influenced  by  the  periosteum,  and 
also  by  the  surrounding  parts  (where  they  form  after  fractures). 
"While  solid  healing  is  due  to  this  new  formation  of  bone  after  frac- 
tures, in  chronic  ostitis  and  periostitis  it  is  more  an  accidental  prod- 
uct of  irritation,  which  subsequently  has  no  further  significance. 
The  same  thing  is  true  in  superficial  necrosis.  When,  from  new  de- 
position of  osteophytes  around  the  sequestrum,  the  bone  becomes 
more  dense  around  the  point  of  disease,  whether  this  be  exfoliation 
of  one  of  the  cranial  bones,  or  a  sequestrum  from  a  sawed  surface, 
it  has  no  further  practical  importance.     It  is  different  in  complicated 


532    CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC. 

fractures :  when  the  broken  ends  or  nearly  loose  fragments  of  bone 
become  necrosed,  the  formation  of  new  bone  in  the  vicinity  may  not 
only  induce  future  firmness  in  the  bone,  but  the  sequestrum  may  be 
entirely  enclosed  by  the  new  bone,  and  it  may  be  necessary  to  remove 
it  by  operation.  But  this  formation  of  new  bone  is  most  important 
in  total  necrosis  of  entire  diaphyses;  it  is  intended  to  replace  the 
bone  which  dies.  This  very  important  process,  which  is  so  wonder- 
fully accomplished  by  Nature,  we  must  now  study  more  carefully. 
Let  us  suppose  an  acute  total  periostitis  and  osteomyelitis  with  ne- 
crosis of  the  diaphysis  of  the  tibia.  The  entire  periosteum  and  me- 
dulla have  suppurated  ;  within  the  bone  the  pus  falls  to  detritus,  or 
actually  putrefies  ;  the  pus  from  the  periosteum  has  perforated  the 
skin  at  various  points,  the  circulation  in  the  diaphysis  has  ceased;  the 
entire  diaphysis  is  a  sequestrum.  A  longitudinal  section  gives  the 
following  appearance  (Fig.  80)  : 

Pig.  80. 


Diagram  of  tota.  necrogie  of  the  diaphysis  of  a  hollow  bone. 


i?,  the  sequestered  bone ;  b  b,  its  upper  and  lower  extremities ;  c  c, 
pus  surrounding  the  sequestrum ;  d  (?,  where  it  has  perforated  exter- 
nally. The  darkest  layer,  e  e,  is  the  wall  of  a  large  abscess-cavity, 
which  consists  of  tissue  (connective  or  tendinous  tissue,  or  even  of 
muscle),  infiltrated  with  plastic  matter,  and  on  its  inner  surface,  which 
lies  next  the  sequestrum,  like  any  abscess-cavity,  it  has  a  granulation- 
layer,  which  constantly  produces  new  pus.  I  will  mention  at  once 
that  this  view,  as  in  acute  periostitis,  difi'ers  from  that  of  other  sur- 
geons and  anatomists,  because  they  suppose  the  tendinous  portion 
of  the  periosteum  is  lifted,  like  a  vesicle,  from  the  bone  by  the  pus ; 
this  is  incorrect,  because  the  tendinous  portion  of  the  periosteum  is 
not  sufficiently  elastic  to  be  quickly  elevated  like  an  epidermis  vesicle, 
and  because  this  elevation  would  fail  to  occur  at  those  points  where 
there  is  no  periosteum,  i.  e,,  where  tendons  are  attached  to  the  bone ; 
but  the  latter  is  not  the  case.     The  inflammation  and  suppuration 


DETACHMENT   OF   THE   SEQUESTRUM.  533 

begin  partly  in  the  surface  of  the  bone,  partly  in  the  softer  parts  of 
the  periosteum,  in  its  outer  layers ;  the  tendinous  portion  participates 
but  little ;  indeed,  it  is  mostly  destroyed.  In  proof  of  this  I  have  very 
decided  anatomical  evidences.  The  anatomists  and  surgeons  v^ho 
believe  in  the  elevation  of  the  periosteum  consider  the  shaded  layer, 
e  e,  as  infiltrated,  thickened  periosteum ;  this  is  only  conditionally 
true :  it  may  happen  that  part  of  the  periosteum  does  not  suppurate 
and  enters  into  the  composition  of  this  layer ;  however,  other  adjacent 
parts  may  also  be  so  indurated  by  plastic  infiltration  as  to  form  a  firm 
abscess  membrane,  as  is  often  seen  in  abscesses  of  the  soft  parts. 
Wlioever  maintains  the  exclusive  power  of  the  periosteum  to  produce 
bone  will,  on  theoretical  grounds,  regard  this  layer,  e  e  (where  bone 
is  subsequently  formed),  as  thickened  periosteum.  But,  in  the  forma- 
tion of  callus,  after  fractures,  we  have  already  seen  that  bone  in  con- 
siderable quantity  may  under  certain  circumstances  be  produced  in 
other  soft  parts  lying  near  the  bone,  and  hence  we  are  not  obliged  to 
demand  periosteum  in  this  thickened  layer  of  the  abscess. 

But  we  are  going  on  too  rapidly.  Let  us  return  to  our  example. 
The  pus-cavity  around  the  sequestrum  cannot  close  till  the  latter  is 
out  of  it;  but  this  remains  attached  at  both  ends.  You  already  know 
how  the  detachment  is  efifected :  at  5  J,  in  the  edges  of  the  living  bone, 
there  is  an  interstitial  proliferation  of  granulations,  by  which  a  slight 
amount  of  bone  is  consumed,  so  that  at  last  the  osseous  substance  is 
entirely  replaced  by  soft  granulations  at  these  ends ;  this  completes  the 
detachment  of  the  sequestrum  (see  page  232) ;  the  granulations  form- 
ing here  break  down  somewhat,  soften  to  pus,  and  then  the  seques- 
trum lies  loose  in  a  pus-cavity,  which  is  filled  with  proliferating  granu- 
lations. In  the  thick  hollow  bones  this  detachment  of  the  sequesti-um 
requires  a  long  time,  usually  several  months,  sometimes  over  a  year ; 
up  to  this  time  the  pus  has  escaped  from  the  places  where  it  had  per- 
forated the  skin ;  if,  during  this  time,  you  introduce  a  probe  through 
the  openings,  you  may  usually  feel  the  smooth  surface  of  the  diaphysis. 
But,  during  this  process  of  detachment  of  the  sequestrum,  something 
else  is  generally  going  on  in  the  immediate  vicinity,  to  which  we  shall 
now  turn  our  attention.  In  the  thickened  layer  of  the  pus-cavity,  e  e, 
new  osseous  tissue  has  formed  regularly  around  the  sequestrum  longi- 
tudinally ;  this  ossification  has  also  continued  to  the  part  where  the 
thickened  layer  again  joins  the  periosteum  of  the  epiphysis  and  the 
capsule  of  the  joint,  so  that  the  bone-capsule  is  intimately  connected 
with  the  epiphysis  above  and  below.  The  longer  the  sequestrum 
remains  in  the  cavity,  the  more  the  bony  envelope  increases  in  thick- 
ness ;  in  time  it  becomes  very  thick;  in  the  course  of  years,  if  the 
sequestrum  does  not  come  out,  it  may  be  over  half  an  inch  thick ;  at 


534     CHRONIC   INFLAMMATION   OF  THE   PERIOSTEUM,  BOXE,  ETC. 

first,  it  consists  of  porous  bone,  but  subsequently  is  more  compact  and 

strono-er.     A  regular  cast  has  been  formed  around  the  sequestrum, 

just  hke  we  should  make  of  plaster  of  Paris  if  we  wish  to  mould  an 

object ;  this  cast,  however,  has  several  openings,  especially  where  the 

pus  escapes ;  their  closure  is  prevented  by  the  constant  flow  of  pus. 

The   above   picture   (Fig.    80)   has   now   changed   to   the  following 

(Fig.  81) : 

Fig.  81. 


D'wjjram  of  total  necrosis  of  the  diaphysis  of  a  hollow  bone,  with  a  detached  sequestrnm  Hud 

new  bony  receptacle. 

The  sequestrum  a  is  detached  and  bathed  in  pus,  which  is  secreted 
from  the  granulations  above  mentioned ;  d  c?,  the  fistulas  leading  into 
the  pus-cavity  (they  have  received  the  name  cloaca) ;  e  e  is  the  bony 
envelope  derived  from  the  ossification  of  the  thickened  abscess-wall, 
the  so-called  bony  receptacle.  This  thickening  now  progresses  regu- 
larly, if  the  irritation  caused  by  the  sequestrum  continues.  Let  us 
now  suppose  that  the  sequestrum  escapes  from  its  case  (as  happens 
occasionally — of  this  later),  then,  although  all  the  bone  of  the  diaphy- 

FiG.  82. 


Fifr.  81,  after  removal  of  the  sequestrum. 


sis  is  lost,  there  is  no  disturbance  of  function,  for  the  newly-formed 
bony  envelope  supplies  the  place  of  the  bone  that  has  been  lost. 

Kow,  what  happens  ?     Will  the  cavity  in  which  the  sequestrum 


DETACHMENT   OF   THE   SEQUESTRUM. 


535 


^y  continue  to  suppurate  ?  No ;  if  every  thing  goes  on  normally, 
this  cavity,  like  other  cavities  due  to  central  caries,  fills  with  granula- 
tions ;  these  granulations  ossify,  and  the  bone  is  completely  restored, 
at  least  as  regards  its  form ;  observation  has  not  yet  determined 
whether  the  medullary  cavity  again  forms  in  such  cases  as  it  does 
after  the  healing  of  fractures,  but  from  analogy  this  is  not  improbable. 
After  removal  of  the  sequestrum,  the  healing  of  these  cavities  often 
requires  months  and  years,  sometimes  it  is  never  complete,  especially 


Fig.  S8. 


Fig.  84. 


0  total  necrosis  of  the  diaphysis  of  fhe  femnr,  nitli 
oxtensive  bony  case  replacing  the  dead  portion  of 
hone ;  several  good-sized  openings  lead  through 
this  bony  case  to  the  seqiiostrum  within. 

b.  longitudinal  section  of  the  same  preparation. 


tibia  of  a  young  man  after  totnl 
necrosis  of  the  ciiaphysis  ;  about 
two  years  previously  I  had  re- 
moved the  sequestrum,  b :  tht 
cavity  has  almost  tilled  with  os- 
teophytes. The  patient  died  frorc 
a  carbuncle. 


536     CHRONIC  INFLAMMATION    OF   THE  PERIOSTEUM,  BONE,  ETC. 

if  the  individual  affected  be  constitutionally  diseased,  or  becomes  so 
from  the  continued  suppuration  accompanying  the  process.  In  these 
long-continued  suppurations  from  bone,  albuminuria  not  unfrequently 
develops,  although  of  rather  mild  form.  I  do  not  know  whether  this 
may  in  time  spontaneously  disappear  after  the  cavity  in  the  bone  has 
healed  ;  it  would  be  interesting  and  of  prognostic  importance  to  collect 
observations  on  this  point.  After  removal  of  the  sequestrum,  the  thick- 
ening of  the  osseous  envelope  ceases,  and  the  process  of  ossification 
establishes  itself  in  the  cavity  filled  with  granulations.  What  I  have 
just  demonstrated  to  you  in  diagrams,  you  here  see  in  these  beautiful 
preparations  from  the  anatomical  and  surgical  collection  of  Zurich. 

You  now  know  the  ordinary  normal  course  of  a  necrosis.  I  must 
next  introduce  you  to  some  deviations  from  this  normal  course.  You 
will  remember  that,  when  speaking  of  acute  periostitis,  I  told  you  that 
occasionally  the  epiphyseal  cartilages  also  ossified  (where  they  still 
existed,  that  is,  in  young  persons).  When  this  takes  place  simulta- 
neously in  the  upper  and  lower  ends  (a  very  rare  case),  of  course  the 
sequestrum  will  be  detached,  and  detached  very  early,  so  early  that 
no  bone  can  have  yet  formed  in  the  pus-cavity,  or,  if  it  has,  it  must 
still  be  very  weak.  If  the  bone  be  now  extracted,  there  is  nothing 
yet  formed  to  replace  it,  nor  does  anything  form,  because  the  irritation 
which  gives  rise  to  the  production  of  bone  is  absent,  this  cause  of  irri- 
tation being  the  sequestrum,  as  long  as  it  remains  as  a  foreign  body 
in  the  bone  ;  hence,  under  these  circumstances,  if  the  sequestrum  be 
extracted  early,  the  extremity  becomes  boneless  and  unserviceable. 
When  the  epiphysis  cartilage  suppurates  at  one  end,  e.  g.,  the  lower 
end,  the  sequestrum  remains  firmly  attached  above,  and  the  break- 
ing down  of  the  bone  must  go  on  slowly  as  in  other  cases ;  it  may, 
however,  happen,  as  I  saw  in  one  case  in  the  thigh,that  the  lower  end. 


Fig.  95. 


Necrosis  of  the  lower  half  ot  the  dlaphysis  of  the  femur,  with  detachment  of  the  e^iDhyseal 
cartilage,  and  perfc  ration  of  the  skin. 


DETACHMENT   OF   THE   SEQUESTRUM. 


537 


loose  in  the  epiphysis  cartilage,  presses  strongly  against  the  skin  from 
within  and  gradually  perforates  it,  so  that  it  appears  externally ;  the 
lower  epiphysis  of  the  femur  was  at  the  same  time  drawn  up  by  the 
muscles,  so  that  the  appearance  was  as  follows  (see  Fig.  85). 

The  sequestrum,  subsequently  removed,  had  the  following  form 
rFig.  86)  : 

Fio.  86. 


The  body  extracted  from  Fig.  85. 

The  formation  of  bone  was  strong  enough  to  carry  the  body ;  sub- 
sequently, under  chloroform,  the  knee  was  straightened,  and  perfect 
recovery  resulted.  I  saw  a  perfectly  similar  case  affecting  the  lower 
end  of  the  humerus.  In  both  cases,  as  is  usual  in  necrosis  near  the 
joints,  the  joint  had  suffered  severely,  and  became  quite  stiff.  Still, 
even  without  early  detachment  of  the  sequestrum  from  softening  of 
the  epiphyseal  cartilages,  under  circumstances  which  we  do  not  accu- 
rately know,  the  formation  of  bone  may  be  very  feeble,  so  that,  after 
the  detachment,  the  new  bone  is  not  firm  at  some  point,  but  is  quite 
flexible,  whereby  we  have  a  pseudarthrosis  of  the  new  bone ;  I  have 
seen  two  cases  of  this  kind  :  one  of  these  I  cured  completely  by  occa- 
sionally driving  ivory  plugs  into  the  weak  part  of  the  newly-formed 
bone,  thus  constantly  stimulating  the  bone  to  new  production ;  the 
object  was  attained  in  the  course  of  eight  months,  and  the  patient, 
then  twelve  years  old,  now  walks  like  a  healthy  person. 


Fig.  87, 


Diagram  of  partial  necrosis  of  a  hollow  bone. 


538     CHRONIC  INFLAMMATION    OF  THE  PERIOSTEUM,  BONE,  ETC. 

Partial  necrosis  of  the  diaphysis  is  more  frequent  than  the  above 
complete  necrosis  ;  this  may  either  affect  the  entire  thickness,  or  only 
half  the  circumference,  according  to  the  extent  of  the  osteomyelitis  and 
periostitis.  You  may  readily  apply  what  has  been  said  to  these  par- 
tial necroses.  Here  is  an  example :  suppose  a  periostitis  of  part  of 
the  diaphysis  of  one  femur  and  subsequent  necrosis  ;  the  circumstancea 
may  assume  the  following  shape  (see  Figs.  87  and  88) :  a,  seques- 
trum ;  b  b,  its  borders ;  c  c,  the  pus-cavity ;  d,  the  perforation  out- 
ward ;  e  e,  the  thickened  ossifj'ing  wall  of  the  pus-cavity. 

A  few  months  later  (Fig.  89) ;  a,  detached  sequestrum,  which  is  to 

Fig.  S8. 


Diagram  of  Fig.  87  in  the  later  stages,  with  formation  of  new  bone. 

l»e  removed ;  e  e,  newly-formed  bone-tissue  as  substitute  for  the  piece 
of  bone  that  is  being  lost ;  of  course,  the  newly-formed  bone  covers 
the  sequestrum  anteriorly,  but,  as  in  Figs.  80,  81,  and  82,  must  be  left 
out  to  expose  to  view  the  sequestrum. 

Fio.  89. 


Fig.  88,  after  removal  of  the  sequestrum. 

The  changes  that  we  have  now  become  acquainted  with  may  also 
1)6  applied  to  'necrosis  in  flat  and  spongy  short  boties  ;  but  at  the  same 


DETACHMENT   OF   THE   SEQUESTRUM. 


539 


time  we  must  remark  that  in  necrosis  of  these  bones  the  new  forma- 
tion is  much  less,  often  entirely  wanting,  because  the  inflammation 
here  is  particularly  of  constitutional  origin,  and  hence  occasionally 
deviates  from  the  normal  course ;  as  a  rule,  the  inflammatory  neo- 
plasia in  necrosis  of  the  spongy  bones  soon  assumes  the  ulcerative 
character,  and  then  the  formation  of  new  bone  is  but  slight ;  more- 
over, acute,  non-traumatic  periostitis  is  something  very  rare  in  spongy 
bones. 

Extensive  necrosis  may  even  occur  after  originally  pure  ossifying 
periostitis  and  ostitis,  in  case  the  newly-formed  ossific  deposit  is  re- 
absorbed, suppurates  and  decomposes  at  the  point  of  its  attachment 
to  the  diseased  bone ;  this  gradually  afi"ects  the  nutrition  of  the  bone ; 
it  often  continues  to  live  for  a  long  time  in  the  medullary  cavity,  or 
rather  leads  a  half  existence  between  living  and  dying ;  this  variety 
of  periostitis  and  necrosis  occurs  especially  in  the  maxillary  bones 
after  chronic  poisoning  by  phosphorous  fumes,  a  disease  peculiar  to 
workers  in  match-factories.  I  cannot  enter  more  minutely  into  this 
phosphorous  periostitis  and  necrosis,  which  has  many  noteworthy 
peculiarities,  because  it  would   be   necessary  to  load  you  with  too 


1.  Scapnla  of  a  yonnff  dofflSO  days  after  the  removal  of  the  dehneated  fra^jment,  which  at  the  time  of  the 

resection  formed  part  of  the  fully-ossified  portion  of  the  scapula;  the  articular  surface,  edges  of  the 
cartilapre,  and  the  carefully-detached  periosteum,  were  all  preserved.  The  growth  of  the  bone  was 
unimpeded,  and  there  was  almost  complete  regeneration  of  the  resected  portion. 

2.  Scapula  of  a  young  dog  of  the  same  litter,  150  days  after  an  operation  performed  the  same  day  as  the 

above,  and  in  the  same  manner,  except  that  the  periosteum  was  removed.  The  growth  was  im- 
paired, and  the  resected  portion  was  not  regenerated. 


540     CHRONIC  INFLAMMATION   OF  THE   PERIOSTEUM,  BONE,  ETC. 

many  details,  which  would  now  confuse  j^ou.  If  j^ou  bear  in  mind 
the  above-desciibed  course  of  necrosis  in  the  hollow  bones,  j^ou  will 
have  the  opportunity  of  learning  in  the  clinic  all  the  deviations  that 
may  occur  in  any  case,  fi'om  peculiar  circumstances,  for  necrosis  is  a 
relatively  frequent  disease  of  the  bones. 

I  cannot  leave  the  anatomy  of  necrosis  and  the  regeneration  of 
bone  accompanying  it,  without  mentioning  an  excellent  French 
worker  who  has  spent  many  years  in  the  study  of  the  osteoplastic 
power  of  the  periosteum,  and  has  nobly  carried  forward  the  pre"vaous 
works  of  D'oja,  Flourens^  B.  Heine,  A.  Wag^ier,  and  others,  on  this 
subject :  I  mean  Oilier,  who,  with  untiring  zeal,  has  pursued  this  study 
experimentally  and  clinically,  and  has  closed  it  up  for  a  long  time  ;  I 
have  repeated  part  of  his  experiments,  and  can  only  confirm  the  idea 
that  under  certain  circumstances,  in  young  animals,  preservation  of 
the  periosteum  decidedly  favors  the  reproduction  of  bone.  In  the 
course  of  these  lectures  I  have  already  stated  my  opinion  regarding 
the  osteoplastic  power  of  human  periosteum,  especially  as  compared 
with  other  soft  parts  surrounding  the  bones,  and  hitherto  I  have  found 
these  views  confirmed  by  every  new  experience. 

Quite  recently  J.  Wolff,  who  was  already  distinguished  by  his 
careful  provings  of  Oilier* s  experiments,  has  advanced  some  entirely 
new  and  interesting  views  on  the  growth  of  bone. 


We  now  pass  to  the  symptoms  and  diagnosis  of  necrosis.  Dis- 
ease of  the  bone  is  called  necrosis  from  the  time  it  becomes  evident 
that  a  part  or  the  whole  of  a  bone  is  dead,  till  the  sequestrum  is  re- 
moved ;  the  subsequent  heaHng  of  the  cavity  in  the  bone  is  usually  a 
simple  development  of  healthy  granulations  with  suppuration,  which 
may,  it  is  true,  assume  an  ulcerative  character.  Now,  the  question 
arises,  How  shall  we  know  that  a  part  is  necrosed?  This  may  be 
very  simple  in  some  cases,  especially  where  the  necrosed  bone  is 
exposed,  that  is,  in  aU  cases  where  necrosis  follows  xmcovering  of  the 
bone ;  the  dead  bone  looks  quite  white,  but  in  some  places  it  be- 
comes blackish,  like  other  dried,  necrosed  parts.  Gangrene  of  the 
bone,  as  far  as  regards  the  bone-substance,  may  remain  as  dry  gan- 
grene ;  the  soft  parts  in  the  bone,  the  vessels,  connective  tissue,  and 
medulla,  may,  however,  like  other  soft  parts,  be  attacked  by  dry  or 
moist  gangrene  ;  perfect  dryness  occurs  in  most  cases  where  the  bone 
is  uncovered,  exposed  to  the  air;  hence  this  superficial  necrosis  is 
rarely  a  process  of  decomposition,  seldom  accompanied  by  bad  smells. 
In  deeply-situated  necrosis,  as  in  that  of  a  whole  diaphysis  or  of  a 
sawed  or  fractured  surface,  which  is  embedded  in  soft  parts,  there  is 


FATE   OF   THE   SEQUESTRUM.  54I 

nsually  decomposition  of  the  medulla ;  the  smell  from  a  large  ex- 
tracted sequestrum  is  occasionally  very  penetrating.  This  decom- 
posing medullary  substance  is  dangerous  as  long  as  no  line  of 
demarcation  has  formed,  while  the  lymphatic  vessels  of  the  vicinity 
are  still  open ;  when  the  proliferation  of  tissue  has  occurred  in  the 
borders  of  the  bone  next  the  healthy  parts,  the  inBammatory  neopla- 
sia forms  a  wall  through  which  reabsorption  does  not  readily  occur. 
How  are  we  to  recognize  a  deeply-situated  sequestrum?  This  can 
only  be  exactly  done  by  the  probe.  Through  the  ojoening  from  which 
the  pus  flows  we  pass  a  probe,  as  large  a  one  as  possible,  with  which 
we  feel  the  surface  of  the  sequestrum,  which  is  usually'  smooth  and 
firm,  more  rarely  rough  and  soft.  We  attempt  to  slide  the  probe 
along  it,  to  determine  the  length  of  the  sequestrum ;  we  also  press  the 
probe  firmly  against  the  sequestrum,  to  find  whether  it  be  movable, 
detached,  or  whether  it  be  still  firm ;  as  you  will  understand,  this  is 
important  in  relation  to  the  question  whether  we  may  as  yet  attempt 
extraction  of  the  sequestrum.  A  fiu-ther  aid  to  diagnosis  is  the  in- 
creased thickness  of  the  extremity ;  we  feel  the  extensive  new  for- 
mation of  bone ;  thick  yellow,  often  mucous,  pus  flows  from  the 
openings;  the  bone  is  not  especially  sensitive  to  pressure;  nor  is 
careful  probing  usually  painful,  although  the  patient  often  dreads  it, 
because  some  surgeons  do  it  with  unnecessary  violence,  but  without 
any  result.     The  patient  is  free  from  fever. 

From  these  points  you  will  readily  diagnose  many  cases  of  ne- 
crosis ;  as  long  as  there  are  no  external  openings,  the  diagnosis  of  cen- 
tral necrosis  of  a  bone  is  liable  to  error.  Caries  is  almost  the  only 
thing  for  which  necrosis  can  be  mistaken ;  the  mode  of  origin  and 
the  locaUty  aid  greatly  in  the  distinction,  for  necrosis  occurs  more 
frequently  as  a  result  of  acute  inflammation  in  the  hollow  bones 
[femur^  tibia,  humerus),  caries  usually  occurring  more  slowly  in 
spongy  bones ;  however,  the  objective  symptoms  are  also  different : 
in  caries  there  is  but  little  formation  of  new  bone  about  the  ulcer, 
often  none  can  be  felt ;  in  necrosis  this  is  extensive :  in  caries  the  pus 
is  thin,  bad,  serous ;  in  necrosis  it  is  thick,  often  good,  frequently  mu- 
cous :  in  caries  we  pass  the  probe  into  rotten  bone,  and  probing  is 
usually  quite  painful ;  in  necrosis  the  probe  generally  strikes  on  the 
firm  sequestrum  and  is  not  often  painful.  From  this  comparison  of 
the  symptoms,  which  result  from  the  different  natures  of  the  two  dis- 
eases, you  must  acknowledge  the  possibility  of  a  diagnosis ;  in  many 
cases,  indeed,  it  is  very  easy  and  simple.  In  other  cases,  the  anatom- 
ical conditions  are  more  difficult  to  understand  ;  when  necrosis  and 
caries  occur  together,  all  the  symptoms,  except  feeling  the  sequestrum 
on  probing,  are  in  favor  of  caries.     In  central  caries  of  the  hollow 


542     CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC. 

bones,  enormous  thickening  of  the  bone  occurs  in  exceptional  cases- 
at  the  same  time  the  inner  wall  of  the  bone-cavity  may  feel  very  firm 
and  hard,  like  a  sequestrum ;  these  cases  may  give  rise  to  error :  on 
opening  the  cavity,  no  sequestrum  is  found,  as  had  been  expected ;  it 
is  possible  that  in  these  rare  cases  the  sequestrum  may  have  been  very 
small  and  may  have  been  absorbed ;  of  this  more  liereafter.  But  these 
exceptional  cases  do  not  disprove  the  rule ;  hence  you  may,  to  a  great 
extent,  confide  in  the  above  comparative  diagnosis. 

Now,  a  few  words  about  the  fate  of  the  sequestrum.  Do  you 
.Tiean  to  say  the  dead  bone  cannot  be  reabsorbed  ?  Have  I  not  told 
you  frequently  that  dead  bone  may  be  dissolved  and  consumed  by  the 
granulations  ?  Hence  we  should  expect  that  the  elimination  of  the 
sequestrum  would  not  require  any  aid.  From  my  observations,  I  have 
no  doubt  that  small  sequestra  may  be  completely  consumed  by  prohf- 
erating  granulations  ;  granulations  that  are  being  destroyed  or  under- 
going cheesy  degeneration  have  no  power  of  dissolving  bone ;  we 
have  already  stated,  when  speaking  of  caries,  that  partial  necrosis  oc- 
curs so  readily  in  atonic  suppurative  or  caseous  ostitis,  just  because 
the  inflammatory  neoplasia,  which  so  quickly  breaks  down  again,  does 
not  dissolve  the  bone,  but  leaves  it  to  be  macerated  in  the  body.  But 
the  reabsorption  of  the  sequestrum  has  its  limits :  first,  of  course,  it 
ceases  wheie  the  bone  is  uncovered,  for  here  the  granulations  have  no 
effect;  it  also  ceases  as  soon  as  they  secrete  pus  on  their  surface; 
hence  a  sequestrum,  resulting  from  acute  periostitis,  is  not  usually 
absorbed  at  the  point  where  the  periosteum  suppurates  and  where  pus 
forms  during  the  whole  process,  because  it  does  not  come  in  contact 
with  tlie  granulations ;  but  at  all  points  where  the  sequestrum  must 
be  loosened,  reabsorption  commences  from  the  interstitial  granulation- 
masses  forming  on  the  bone  ;  lastly,  after  the  sequestrum  is  detached, 
if  these  granulations  also  produce  pus,  reabsorption  ceases  here  also, 
and  the  sequestrum  bathed  in  pus  ceases  to  decrease;  the  granula- 
tions of  the  pus-cavity,  growing  from  all  sides  toward  the  sequestrum, 
in  the  course  of  time  undergo  chemical  change ;  they  become  very 
gelatinous,  mucous,  and  often  undergo  fatty  degeneration. 

But  the  sequestrum  must  finally  come  out.  Can  it  do  so  un- 
aided ?  This  does  occur ;  whence  the  power  that  pushes  it  out  ?  Let 
us  suppose  a  central  necrosis ;  a  sequestrum  becomes  detached  from 
all  sides ;  then,  for  the  reasons  above  mentioned,  it  is  considerably 
smaller  than  the  cavity  in  which  it  lies ;  the  piece  of  bone  is  now 
quite  loose ;  granulations  grow  toward  it  from  all  sides  except  from 
the  one  where  the  pus-cavity  opens  externally ;  here  there  is  no  re- 
sistance ;  if  the  opening  be  large  enough,  the  constantly-increasing 
granulations  push  out  the  sequestrum.     But  for  this  to  occur  there 


SEQCESTROTOMY.  543 

must  be  certain  mecliauical  conditions  which  are  rarely  fulfilled  ;  small 
sequestra  are  often  throAyn  off  spontaneously ;  large  ones,  which  can- 
not pass  the  existing  openings,  must  be  removed  artificially. 

The  treatment  of  necrosis  at  first  consists  simply  in  keeping  the 
fistul®  clean.  Chemical  solution  of  the  sequestrum  is  not  to  be 
thought  of.  If  you  were  daily  to  pour  muriatic  acid  into  the  fistulous 
opening,  it  would  affect  the  newly-formed  osseous  tissue  as  much  as, 
or  more  than,  it  would  the  sequestrum,  which  would  be  very  unfortu- 
nate, as  it  must  replace  the  latter.  Hence  the  tnechanical  removal 
of  the  sequestrum  is  the  only  thing  left ;  this  should  not  be  attempted 
before  complete  detachment.  Tliis  is  a  very  important  rule :  first,  be- 
cause the  dead  bone  can  rarely  be  sawed  out  without  removing  a  good 
deal  of  the  healthy  and  of  the  newly-formed  bone,  both  of  which  are 
bad ;  and,  secondly,  because  the  new  bone  is  rarely  firm  enough  before 
the  sequestrum  is  detached.  Here,  again,  we  meet  a  wonderful  pro- 
vision of  Nature :  the  sequestrum  is  not  generally  detached  till  the 
new  formation  of  bone  is  strong  enough  to  replace  the  lost  portion  of 
bone.  This  beneficent  provision  should  not  be  brought  to  naught  by 
meddlesome  interference.  There  are  only  a  few  special  exceptions  to 
the  above  rule,  especially  in  necrosis  from  phosphorus,  which  is  not 
a  pure  necrosis,  but  is  often  combined  with  caries ;  but  of  this  we 
shall  treat  more  particularly  in  special  surgery  and  in  the  clinic. 

I  have  already  told  you  that  we  may  sometimes  tell  by  the  probe 
whether  a  sequestrum  is  detached ;  but  this  is  not  always  so ;  it  may 
be  so  shut  in  by  granulations  that  it  cannot  be  felt  to  move.  It  is 
always  hard  to  decide  on  the  mobility  of  a  large  sequestrum  ;  and  the 
cm-ved  shape  of  the  bone  (as  of  the  lower  jaw)  may  greatly  interfere 
with  the  decision.  In  such  doubtful  cases  the  duration  of  the  pro- 
cess, and  the  thickness  of  the  bony  case,  are  important  aids  in  deter- 
mining whether  the  sequestrum  be  detached  or  not.  Most  sequestra 
are  usually  detached  in  eight  or  ten  months ;  in  a  year  even  an 
entire  necrotic  diaphysis  usually  lies  as  a  loose  sequestrum  in  the 
newly-formed  bony  case.  These  are  approximate  determinations, 
which  may  of  course  have  exceptions.  If  the  formation  of  bone  be 
still  weak,  and  nevertheless  the  sequestrum  be  already  detached,  it 
is  well  to  postpone  the  extraction  in  the  humerus,  tibia,  and  femur, 
so  that  the  formation  of  bone  may  be  firmer,  provided  the  general 
health  does  not  sufibr.  Should  albuminuria  begin,  the  extraction 
should  be  hastened. 

Extraction  of  the  sequestrum,  especially  when  it  requires  prelimi- 
nary enlargement  of  the  cloaca  (fistulas  leading  into  the  bony  case), 
is  called  the  operation  for  iiecrosls  or  sequestrotomy.     This  operation 


544     CHRONIC   INFLAMMATION   OF  THE  PERIOSTEUM,  BONE,  ETC. 

may  be  very  simple.  If  one  of  the  openings  of  the  bony  ease  be 
tolerably  large,  and  the  sequestrum  small,  we  may  pass  a  good  pair 
of  forceps  through  the  opening  and  try  to  seize  and  remove  the  se- 
questrum. If,  as  in  caries  necrotica,  there  be  no  formation  of  new 
bone,  we  enlarge  the  fistulous  opening  through  the  soft  parts  with 
a  knife,  and  remove  the  necrosed  piece  of  bone.  But,  if  the  openings 
be  small  and  the  sequestrum  large,  a  portion  of  the  bony  case  must 
be  removed,  both  for  the  purpose  of  introducing  instruments  for  ex- 
traction and  for  removing  the  sequestrum.  In  rare  cases,  it  is  suffi- 
cient to  enlarge  one  opening  with  trepan,  chisel,  and  hammer.  I 
usually  do  the  operation  as  follows  :  With  a  stout  knife  I  make  an  in- 
cision through  the  soft  parts  down  to  the  bony  case,  from  one  fistulous 
opening  to  an  adjacent  one ;  then,  ^^^th  a  handled  scraper,  a  raspa- 
torium,  I  draw  the  thickened  soft  parts  from  the  rough  surface  of  the 
bony  case,  so  as  to  expose  it  to  a  certain  extent.  This  exposed  por- 
tion should  now  be  removed,  to  make  an  opening  through  which  the 
sequestrum  may  be  removed.  For  this  purpose  we  may  use  saws  of 
various  kinds — the  osteotome,  the  panel-saw,  etc. ;  of  late,  I  always 
employ  chisel  and  hammer ;  the  work  is  laborious,  use  what  instru- 
ments we  will.  The  portion  of  the  bony  case  removed  should  be  as 
small  as  possible,  so  as  to  interfere  the  less  with  its  firmness.  WTien 
the  case  is  opened,  the  sequestrum  is  exposed  ;  we  attempt  its  removal 
by  elevators  or  with  strong  forceps ;  this  also  is  sometimes  very  trouble- 
some.    When  the  removal  is  accomplished,  the  indication  is  fulfilled. 

If,  contrary  to  expectation,  the  sequestnim  be  found  not  detached, 
we  should  avoid  forcing  it  out,  but  wait  a  few  weeks  or  months,  till 
we  are  satisfied  of  its  detachment.  After  the  operation,  the  suppu- 
rating cavity  in  the  bone  is  to  be  kept  clean  ;  the  patient  should  keep 
his  bed  for  some  time ;  most  fistulas  soon  cease  discharging,  but  it  is 
still  some  time  before  the  sequestrum-cavity  is  filled  with  ossifying 
granulations.  We  cannot  do  much  to  hasten  this,  and  the  fistulse, 
which  sometimes  remain  a  long  while,  usually  cause  so  little  trouble 
that  we  are  not  often  called  on  to  do  any  more  operations  for  them. 
Occasionally,  however,  too  large  an  opening  remains  for  a  long  time, 
its  walls  become  sclerosed  and  cease  to  granulate ;  here  we  apply  the 
treatment  for  atonic  ulcers  of  the  bone.  In  these  old  cases,  the  hot 
iron  to  the  cavity  in  the  bone,  and  chiselling  out  the  track  of  the  fis- 
tula, is  the  only  treatment  from  which  I  have  ever  seen  any  benefit. 
Many  cases  of  these  bone-fistulae  are  incurable. 

The  full  value  of  sequestrotomy  has  only  been  appreciated  for  the 
past  ten  years;  it  first  became  common  after  the  introduction  of 
chloroform,  for  it  is  a  terrifying  operation.  This  chiselling,  sawing, 
and  hammering  on  the  bones,  are  horrible  for  a  looker-on,  and  the  more 


RACHITIS.  545 

so  as  the  operation  may  last  some  time ;  amputation  is  a  trifle  in 
comparison.  Local  anaemia  (as  induced  by  Esmardi's  bandage) 
greatly  facilitates  tbe  recognition  of  the  anatomical  conditions  in 
these  operations.  Formerly  amputations  were  frequently  performed 
for  total  necrosis,  a  thing  that  no  surgeon  would  do  now.  Hence,  in 
old  museums,  you  find  the  most  beautiful  preparations  cf  extensive 
necroses  ;  now  these  are  rarely  found,  because  almost  all  sequestra 
are  removed  at  the  proper  time.  Locally  the  operation  is  quite  ex- 
tensive, but  the  febrile  reaction  is  usually  slight.  Severe  as  the  in- 
flammatory symptoms  and  fever  might  be  if  you  were  to  treat  a 
healthy  bone  in  the  same  way,  the  effect  on  the  bony  case  of  the 
sequestrum  is  but  slight.  From  my  own  experience,  I  do  not  know 
of  a  case  which,  after  such  an  operation,  even  where  the  entire  bony 
case  was  opened  in  total  necrosis  of  the  tibia,  turned  out  badly ; 
and  I  am  satisfied  that  the  operation  for  necrosis  is  one  of  the  most 
successful  of  operations,  and  that  by  it  many  lives  are  saved,  such  as 
were  formerly  lost  from  amputation,  from  constitutional  diseases  due 
to  continued  suppuration  from  the  bone,  or  from  fatty  degeneration 
of  internal  organs,  morbus  Brightii,  and  tuberculosis. 


LECTURE    XXXVI. 

APPENDIX  TO  CHAPTER  XVI. 

Eachitis  :    Anatomy,    Symptoms,    Etiology,    Treatment. — Osteomalacia. — Hypertro- 
phy and  Atrophy  of  Bone. 

Rachitis  and  Osteomalacia. — We  must  still  touch  on  two  consti- 
tutional diseases,  which  are  chiefly  manifested  in  certain  changes  of 
the  bone,  namely,  softening.  They  are  called  rachitis  and  osteoma- 
lacia. Their  effects  in  changing  the  form  of  the  bone  are  much 
alike,  but  their  natures  differ  somewhat.  They  cannot  be  exactly 
classed  amono-  the  chronic  inflammations,  although  nearest  related 
to  this  process. 

Let  us  begin  with  rachitis.  The  name  comes  from  pdxi-^,  the 
backbone,  and  properly  signifies  inflammation  of  the  spine;  but  the 
vertebrae  rarely  sufi"er  much  in  rachitis  ;  hence  the  origin  of  the  name 
is  not  very  clear ;  subsequently  it  was  often  called  "  English  dis- 
ease," because  it  was  particularly  well  known  to  English  writers, 
and  probably  also  was  especially  frequent  in  England. 

The  essence  of  the  disease  consists  in  deficient  deposit  of  chalky 
salts  in  the  growing  bone,  and  remarkable  thickness  of  the  epi- 
physeal cartilages.  You  will  abeady  see  that  this  disease  is  peculiar 
36 


546       CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC. 

to  childhood  ;  it  is  a  disease  of  the  development  of  bone,  which  how- 
ever usually  affects  so  many  bones  that  it  must  be  regarded,  not  as 
a  local,  but  as  a  constitutional  disease,  which  you  may  reckon  among 
the  dyscrasise  already  known  to  you.  The  insufficient  deposit  of 
chalky  salts  in  the  growing  skeleton  in  rachitis  is  accompanied  by  ab- 
normal development  of  vessels  and  increased  absorption  of  the  bony 
tissue  already  developed  (during  the  growth  of  bone  there  is  always 
a  slight  amount  of  absorption  at  the  inner  and  outer  surface  of  the 
cortical  layer),  as  well  as  unusual  proliferation  of  the  epiphyseal  car- 
tilages ;  if  you  remember  also  the  young  osteophytes  forming  on  the 
outsides  of  the  hollow  bones,  it  must  be  acknowledged  that  this  dis- 
turbance of  nutrition  can  scarcely  be  distinguished  from  inflamma- 
tion, even  if  it  passes  on  to  suppuration  and  caseous  degeneration. 
We  often  find  racliitic  symptoms  in  scrofulous  children,  and  some 
physicians  regard  the  disease  as  one  symptom  of  scrofula  ;  but  this 
is  not  quite  correct,  for  in  many  rachitic  children  we  find  no  traces 
of  scrofula,  among  which  are  especially  reckoned  tendency  to  swell- 

FiG.  91. 


Typical  illustrations  of  rachitic  malformations  of  the  leg. 


ing  of   lymphatic   glands,   suppuration,   and  caseous    degeneration. 
Moreover,  the  rachitic  process  has  little  anatomical  connection  with 


RACHITIS.  547 

the  forms  of  periostitis  and  ostitis  that  we  have  studied  in  scrofulous 
children,  for  it  never  leads  to  caries.  The  disproportion  between 
the  growth  of  the  bone  and  deficient  impregnation  of  its  tissue  with 
chalky  salts  results  in  lack  of  firmness  of  the  bones ;  consequently 
they  bend,  especially  those  that  bear  the  weight  of  the  body.  Where 
the  bones  are  very  soft,  muscular  contraction  also  acts  on  them  so  as 
to  induce  curvature.  These  curvatures  are  most  common  in  the 
lower  extremities;  the  femur  bends  anteriorly  and  inwardly,  the 
bones  of  the  leg  bend  anteriorly  and  outwardly  or  inward.  The  tho- 
rax is  compressed  laterally  so  that  the  sternum  projects  sharply,  and 
the  result  is  the  so-called  chicken-breast  {^oectus  carinatum).  In 
high  grades  of  rachitis  there  are  also  distortions  of  the  pelvis,  spinal 
column,  and  upper  extremities.  In  such  children  the  occiput  long 
remains  soft  and  compressible,  and  dentition  is  delayed.  Sometimes 
the  softness  of  the  occiput  is  the  sole  symptom  of  rachitis,  so  that 
this  has  even  been  regarded  as  independent  of  the  general  rachitic 
disturbance.  According  to  Yirchow,  the  distortion  of  the  upper 
extremities  depends  mostly  on  a  number  of  small  curvatures  (infrac- 
tions) of  the  entire  bone,  or  of  parts  of  the  cortical  layer.  Complete 
fractures  rarely  occur ;  if  they  do,  the  bone  is  again  united  firmly  by 
callus,  under  the  ordinary  treatment. 

Rachitis  causes  other  changes  in  the  bone  besides  these  deformi- 
ties, namely,  thickening  of  the  epiphj^ses  and  of  the  point  of  union 
between  the  costal  cartilages  and  the  bony  ribs.  The  thickening  of 
the  epiphyses  may  be  so  great,  at  the  lower  end  of  the  radius,  for 
instance,  that  above  the  wrist,  at  the  point  just  above  the  epiphy- 
seal cartilage,  there  is  a  second  depression  in  the  skin  ;  this  appear- 
ance of  the  joint  has  given  rise  to  the  term  "  double-jointed ; "  the 
nodular  thickenings  on  the  anterior  ends  of  the  ribs  are  often  very 
remarkable,  and,  as  they  lie  regularly  under  one  another,  they  have 
been  called  the  "  rachitic  rose-garland."  If  these  changes  in  the  bone 
have  taken  place,  there  is  no  hesitation  in  diagnosing  rachitis ;  before 
they  have  become  evident,  the  diagnosis  is  doubtful.  It  is  true,  there 
are  some  prodromal  symj)toms  :  voracious  appetite,  pot-belly,  disin- 
clination to  standing  and  walking  ;  but  these  symptoms  are  always 
too  undecided  to  permit  any  definite  conclusion.  The  disease  most 
frequently  begins  in  the  second  year,  and  attacks  well-nourished  or 
even  fat  children  ;  indigestion  and  inclination  to  constipation  occur 
occasionally,  but  not  always.  We  know  little  of  the  exciting  causes 
of  rachitis ;  here  in  Germany  it  is  about  equally  frequent  in  all  classes 
of  society ;  hereditary  influence  may  have  some  effect ;  we  may  sus- 
pect, but  cannot  prove,  a  disturbance  in  the  composition  of  the  blood, 
in  the  assimilation  of  nutriment.     In  regai'd  to  the  course  of  the  dis- 


548     CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC. 

ease,  under  proper  treatment  it  often  subsides  quickly ;  that  is,  the 
symptoms  of  distortion  of  the  bone  cease,  or  rather  do  not  increase; 
the  children,  who  had  ceased  to  walk,  again  desire  to  do  so.  As  the 
normal  growth  of  the  bone  goes  on,  the  distortions  become  less  per- 
ceptible, and  often  disappear  entirely;  this  may  be  readily  under- 
stood from  the  nature  of  the  growth  of  the  bone.  Before  the  bones 
again  acquire  their  normal  consistence,  at  the  end  of  the  rachitic 
process,  there  is  usually  an  abnormally  rich  deposit  of  bone,  so  that 
in  certain  stages  the  rachitic  bones  are  abnormally  hard  and  firm  ; 
that  is,  in  a  sclerosed  state.  Rai-ely,  rachitis  lasts  till  the  skeleton 
has  attained  its  growth,  and  these  cases  furnish  the  excessive  distor- 
tions and  dislocations  that  are  usually  presented  as  types  of  this  dis- 
ease. In  every  pathological  anatomical  colleclion  you  find  examples 
of  such  rachitic  skeletons. 

The  greater  my  experience,  the  more  I  am  inclined  to  regard  flat 
foot^  genu  valyum  and  varum^  as  well  as  latet'cil  curvatures  of  the 
spine  (scoliosis),  as  being  due  to  weakness  of  the  bones,  which  can- 
not be  distinguished  from  a  mild  form  of  rachitis.  This  localized 
rachitis  comes  later  in  life,  it  is  true,  but  it  is  generally  between  ten 
and  twenty  years,  while  the  disease  briefly  termed  rachitis,  as  above 
stated,  is  mostly  seen  in  very  young  children;  still  both  cases  are 
due  to  the  bones  remaining  soft  and  to  pliability  of  growing  bones, 
besides  which  various  other  causes  must  act  to  induce  the  above- 
mentioned  distortions. 

Hereafter  you  will  often  hear  that  some  physicians  think  there  is 
a  direct  relation  between  rachitis  and  infantile  diseases  of  the  brain, 
especially  paralyses,  spasms,  and  psychical  disorders.  I  will  not  deny 
that  this  rather  obscure  disease  may  directly  affect  the  development 
of  the  brain,  but  in  most  cases  it  does  so  indirectly.  The  rachitic 
process  in  the  cranial  bones  is  often  followed  by  rapid  sclerosis,  by 
such  formation  of  new  bone  that  even  the  cranial  sutures  may  ossify; 
this  interferes  wdth  the  regular  growth  of  the  skull,  which  becomes 
irregular,  and  here  and  there  too  small  for  the  growing  brain,  and 
thence  arise  functional  disturbances  of  the  brain. 

Rachitic  children  are  rarely  brought  to  the  doctor  before  the 
parents  notice  the  thick  limbs  or  distortion,  or  until,  as  the  mother 
expresses  it,  "  they  are  off  their  legs,"  i.  e.,  they  no  longer  wish  to 
stand  or  walk,  as  they  formerly  did  ;  the  disease  is  so  common  and 
so  well  known  that  often  it  needs  no  surgeon  for  its  recognition. 
As  a  rule,  treatment  has  only  one  indication,  that  is,  to  remove  the 
diathesis ;  hence  it  is  chiefly  medical,  and  especially  dTetetic.  Re- 
garding the  latter,  the  patient  should  avoid  too  free  use  of  bread, 
potatoes,  mush,  and  flatulent  vegetables ;  he  should  freely  consume 


RACHITIS.  649 

milk,  eggs,  meat,  and  good  white  bread,  and  should  take  strengthen- 
ing baths  of  malt,  herbs,  etc.  Internall}^  we  should  prescribe  cod- 
liver  oil,  iron,  and  similar  strengthening  and  tonic  remedies.  We 
might  think  of  giving  preparations  of  lime,  but  they  are  so  indigest- 
ible, and  are  so  quickly  excreted  by  the  urine,  that  they  do  no  good  : 
they  have  almost  been  thrown  aside ;  it  is  possible,  also,  that  rachitis 
is  essentially  a  disease  of  digestion,  in  which  the  preparations  of  lime 
are,  from  some  unknown  cause,  not  absorbed.  It  is  rather  a  one- 
sided view  to  suppose  that  in  rachitis  or  osteomalacia  lack  of  supply 
of  lime  is  the  cause  of  absence  of  deposit  of  chalky  salts  in  the 
bones,  of  the  disappearance  of  that  which  has  been  deposited.  It  is 
also  possible  that  lime  entering  the  stomach,  from  faulty  digestion, 
does  not  reach  the  blood,  or  that  it  is  excessively  excreted  by  the 
kidneys,  or  perhaps  the  newly-formed  bony  tissue  does  not  take  up 
the  chalky  salts  brought  to  it  in  normal  or  even  in  excessive  amounts. 
It  is  true,  these  points  furnish  no  direct  indications  for  treatment, 
but  I  mention  them  so  that  you  may  see  that  we  are  not  physiologi- 
cally justified  in  referring  the  disturbed  nutrition  solely  to  deficient 
supply.  Frequently  the  parents  ask  for  splints  to  remove  the  curva- 
tures, or,  at  least,  prevent  their  increase ;  they  will  also  ask  you 
whether  the  children  should  be  urged  to  walk,  or  permitted  to  lie 
still.  On  this  point  it  is  best  to  let  children  have  their  own  way : 
if  they  do  not  wish  to  go,  do  not  urge  it ;  if  they  lie  still  more  than 
they  run  about,  they  should  be  kept  in  the  open  air  as  much  as 
possible ;  taking  children  from  a  damp  city  dwelling  to  the  country 
often  suffices  for  the  cure  of  rachitis.  Splint  boots  and  similar  ap- 
paratuses, that  load  the  feet,  should  only  be  applied  in  cases  of  ex- 
cessive curvature,  where  the  position  of  the  feet  mechanically  inter- 
feres with  walking;  this  state  of  affairs  is  rare,  hence  the  indication 
for  such  orthopedic  apparatus  is  limited. 

When  the  rachitis  has  disappeared,  such  amount  of  curvature  may 
remain  in  rare  cases  as  to  require  some  treatment ;  in  the  great  ma- 
jority of  cases  this  is  unnecessary^,  since,  as  already  stated,  the  cur- 
vatures spontaneously  disappear  with  the  growth  of  the  skeleton. 
Only  in  the  leg  curvatures  sometimes  remain,  so  that  the  foot  is  dis- 
torted, and  only  its  inner  or  outer  border  can  be  placed  on  the  floor ; 
if  this  remains  for  years  at  the  same  point,  an  attempt  should  be 
made  at  straightening.  This  may  be  done  in  two  ways.  We  antes- 
thetize  the  child,  and  carefully  fracture  the  bone  subcutaneously ; 
have  the  leg  held  straight,  apply  a  plaster-bandage,  and  treat  the 
injury  as  a  simple  fracture  ;  recovery  usually  takes  place  readily. 
In  some  cases,  however,  after  the  rachitis  has  run  its  course,  the 
bone  is  so  very  firm  that  this  breaking  does  not  succeed.     Then  sub- 


550       CHRONIC  INFLAMMATIOX  OF  THE  PERIOSTEUM,  BONE,  ETC. 

cutaneous  osteotoni}^,  according  to  B.  von  Langenhech  (p.  230),  is  in- 
dicated. The  results  of  this  operation,  which  I  have  had  to  make  four 
times,  have  so  far  been  very  satisfactory  ;  in  one  of  these  cases  the 
skin-wound  healed  by  first  intention,  and  the  subsequent  treatment 
Avas  that  of  simple  fracture.  The  operation  will  always  remain  a  rare 
one,  because  these  excessive  rachitic  distortions  are  themselves  rare. 


Now,  a  few  words  about  osteomalacia,  bone-softening,  Kar''  ^oxrjv. 
The  disease  only  occurs  in  adults,  and  is  also  characterized  by  distor- 
tion of  the  bones ;  but  here  there  is  an  actual  reabsorption  of  exist- 
ing bone.  In  the  hollow  bones  the  medulla  gradually  assumes  the 
preponderance,  while  the  cortical  substance  becomes  thinner  and 
thinner,  and  consequently  the  bones  weaker  and  more  flexible;  and 
finally  there  may  be  a  complete  absorption  of  the  bone,  so  that  little 
is  left  besides  the  periosteum,  which  participates  rarely,  and  then 
but  little,  in  the  disease,  scanty  osteophytes  growing  from  it.  The 
spongy  bones  also  grow  weaker,  the  trabeculae  thinner,  and  become 
so  soft  that  they  shrink.  The  medulla  appears  reddish  and  gelati- 
nous, but  does  not,  as  in  fungous  caries,  consist  solely  of  granulations; 
it  contains  much  fat.  The  microscopic  appearances  in  this  process 
have  already  been  described  in  ostitis  malacissans.  Lactic  acid  has 
been  found  in  the  medulla  of  the  hollow  bones,  so  that  it  is  very 
probable  that  the  bones  are  dissolved  by  it.  The  lime  going  into  the 
blood  is  often  excreted  in  the  urine  as  oxalate  of  lime.  So  j^ou  see 
that  this  is  an  ostitis  malacissans  with  nothing  peculiar  in  its  anato- 
my, but  which  owes  its  distinction  to  its  affecting  many  bones  simul- 
taneously, often  occurring  under  peculiar  conditions,  and  never  lead- 
ing to  suppuration  or  caseous  degeneration. 

Concerning  the  etiology  of  the  disease  we  know  but  little  ;  osteo- 
malacia is  particularly  frequent  in  some  parts  of  Europe,  and  among 
women  ;  it  attacks  tlie  latter  more  particularly  while  in  the  puerperal 
condition  ;  occasionally  it  is  preceded  by  drawing  pains  and  soreness 
on  moving,  which  continue  through  the  disease.  The  distortions 
occur  chiefly,  primarily,  even  solely,  in  the  pelvis,  which  assumes  a 
peculiar,  laterally-compressed  form,  of  which  you  will  hear  more  in 
obstetrics.  This  is  followed  by  curvature  of  the  spine  and  lower  ex- 
tremities, with  muscular  contractions.  The  disease  may  pause,  and 
exacerbate  with  a  new  pregnancy,  etc.  Slight  grades  and  localized 
forms  of  osteomalacia,  as  that  of  the  pelvis,  not  unfrequently  recover 
spontaneously  ;  if  the  disease  be  of  a  high  grade,  general  marasmus 
occurs,  and  the  patient  dies.  The  treatment  is  the  same  as  in  rachitis, 
but  the  hopes  of  success  are  less. 


OSTEOMALACIA. 


551 


Tlie  cases  of  local  osteomalacia  or  osteoporosis,  which  often  accom- 
pany caries,  are  more  interesting  to  us  than  the  above-described  gen- 
eral osteomalacia.  I  will  relate  you  a  case  that  will  at  once  exjDlain 
what  I  mean  :  A  woman,  about  forty  years  old,  was  brought  to  the 
hospital  for  extensive  caries  of  the  knee-joint ;  she  was  excessivelj' 

Fig.  92. 


Woman  with  excessive  osteomalacia,  after  MoranrJ.    The  bones  consist  mostly  of  membranous  cylin- 
ders, or  very  thin  layers  of  bone. 

marasmic,  and  died  the  following  day.  On  autopsy  we  found  com- 
plete fatty  degeneration  of  the  liver,  spleen,  and  kidneys  ;  in  the  knee 
the  condyles  of  the  femm-  and  tibia  were  extensively  destroyed  by  the 
carious  process.  I  sawed  off  the  lower  end  of  the  femur  to  remove 
the  preparation,  and  found  that  it  was  very  much  thickened ;  the  cor- 
tical layer  measured  scarcely  half  a  line ;  the  medulla  was  reddened, 
and  resembled  that  in  osteomalacia ;  the  thinning  extended  upward 
to  the  trochanter.  I  examined  the  tibia  of  the  diseased  leg,  the  femur 
of  the  healthy  one,  and  the  pelvis,  and  found  them  all  pei'fectly  normal ; 
that  is,  only  the  femur  of  the  diseased  leg  was  osteomalacic.     In  the 


552    CHRONIC  INFLAMMATION  OF  THE  PERIOSTEUM,  BONE,  ETC. 

same  way  I  once  found  tlie  lower  half  of  the  tibia  affected  with  osteo- 
malacia, in  caries  of  the  ankle.  There  was  apparently  the  same  thing 
in  a  child  that  had  the  head  of  one  femur  removed  for  caries  of  the 
hip-joint.  I  assisted  in  this  operation  ;  as  I  was  on  the  point  of  lift- 
ing the  thigh  and  rotating  it  outward  to  aid  the  operator,  the  thigh 
broke  through  the  middle,  right  in  my  hands  ;  a  plaster-bandage  was 
applied,  and  the  fracture  recovered ;  the  child  was  completely  restored. 
In  other  cases,  however,  after  fractures  of  bones  with  osteomalacia,  in 
the  so-called  fragilitas  ossium,  pseudarthroses  are  apt  to  remain. 


I  will  also  mention  hyperiropJiy  and  atrophy  of  bone,  which,  how- 
ever, have  more  anatomical  than  clinical  interest. 

Anatomically  we  may  call  any  bone  hypertrophic  which  is  enlarged 
in  length  or  thickness.  There  are  very  few  cases  where  single  hollow 
bones,  as  one  femur  or  one  tibia,  are  excessive  in  length,  and  give 
rise  to  inequahty  of  the  extremities ;  for  this  excessive  growth  I  ac- 
cept the  name  "  hypertrophy  of  bone,"  or,  better,  "  giant-growth  " 
("  riesenwuchs  ") ;  still,  to  give  this  term  to  every  thickening  or  scle- 
rosis would  be  of  no  practical  value,  although  anatomically  correct, 
because  these  conditions  of  the  bone  may  depend  on  very  different 
morbid  processes,  partly  active,  partly  completed.  Even  more  indefi- 
nite is  the  term  atrophy  of  the  bone ;  occasionally,  a  carious,  osteo- 
malacia!, or  a  half-destroyed  bone,  etc.,  is  thus  designated.  This  is  of 
no  practical  value ;  we  do  not  mean  to  deny  that  there  may  be  atrophy 
of  the  bone  without  a  true  morbid  process.  Senile  atrophy,  as  of 
alveolar  process  of  the  jaw,  is  a  striking  example  of  this.  Here  the 
term  atrophy  of  bone  may  be  retained ;  in  most  other  cases  it  would 
be  better  to  name  the  process  that  has  induced  the  atrophv. 

\Kas80xoitz  has  lately  made  some  investigations  as  to  the  nature 
of  rachitic  disease  of  the  bone.  According  to  his  view,  around 
each  blood-vessel  of  the  bone  there  is  normally  an  absorption  of  the 
bone  caused  by  currents  of  fluid,  and  probably  effected  by  the  free 
carbonic  acid  of  the  blood  ;  and  that,  in  rachitis,  chronic  hyperseraia 
and  morbidly-increased  new  formation  of  vessels  in  the  ossifying 
cartilage  and  in  the  periosteum  as  well  as  in  the  growing  bone,  are 
the  causes  of  the  hinderance  of  the  deposit  of  chalky  salts  and  of  the 
increased  absorption  of  those  already  deposited.  The  holes  left  by 
absorption  of  the  bone  fill  with  young  bony  tissue  ;  but  this  does 
not  ossify  normally.  He  thus  explains  the  irregular  form  of  the 
bony  lamellae,  and  of  the  surface  of  the  bone  as  found  in  rachitic 
skeletons. 

RoMtansJcy  had  already  asserted  that  rachitis  was  connected 


RACHITIS.  653 


with  vascular  development,  and,  from  recent  knowledge  of  the 
power  of  carbonic  acid  in  dissolving  bone,  it  is  probable  that  the 
softening  is  due  to  the  vascularity.  Investigations  about  the 
growth  of  bone,  ossification,  and  reabsorption,  are  so  difficult  that  it 
need  not  astonish  you  that  there  is  no  universally  accepted  theory 
on  this  point.] 


CHAPTER  XVJI. 
CSBOJSriC  INFLAMMATION'  OF  THE  JOINTS. 


LECTURE    XXXVII. 

General  Eemarks  on  the  DistinguisHng  Characteristics  of  the  Chief  Forms. — A.  Fun- 
gous and  Suppurative  Articular  Inflammations  (Tumor  Albus),  Symptoms,  Anato- 
my, Caries  Sicca,  Suppuration,  Atonic  Forms. — Etiology. — Course  and  Prognosis. 

Ix  more  than  half  the  cases  of  chronic  inflammation  of  the  joints, 
the  synovial  membrane  is  the  part  first  affected ;  this  affection  may 
be  accompanied  by  more  or  less  secretion  of  fluid,  and  this  fluid  may 
be  purely  serous  or  purulent.  Chronic  serous  synovitis  [hydrojJS 
articulorwn  chroniciis),  unless  from  some  external  cause,  is  no  more 
apt  to  become  purulent  synovitis  than  is  chronic  articular  rheumatism, 
But  other  forms  of  chronic  inflammation  of  the  joints  may  be  accom- 
panied by  suppuration  from  the  first,  or  else  may  be  characterized  by 
the  formation  of  numerous  granulations.  The  two  chief  groups  of 
chronic  articular  inflammation  are  characterized  by  the  condition  of 
the  syno\aal  membrane  even  more  than  by  the  quality  of  the  fluid 
contained  in  the  joint ;  when  the  secretion  is  purely  serous,  the  syno- 
vial membrane  is  somewhat  thickened,  it  is  true  ;  the  tufts  are  en- 
larged, and  their  apices  are  somewhat  raore  vascular  than  normal, 
still  these  changes  are  never  so  extensive  as  to  greatly  injure  the 
membrane  ;  but  in  the  other  variety  of  chronic  inflammation  the  mem- 
brane changes  greatly,  and  is  gradually  transformed  into  a  spongy 
(fungous)  mass  of  granulations,  which  often,  but  not  always,  produces 
pus,  opens  outwardly  (fistula,  cold  abscess),  causes  distortion  of  the 
cartilages  and  bones,  and  may  thus  induce  peripheral  caries  of  the 
epiphysis.  This  latter  group,  which  has  several  subvarieties,  we  shall 
terra  fungous  and  siq:>pur  at  ive  inflammations  of  the  joints  /  they  form 
the  great  majority  of  aU  articular  inflammations,  and  hence  will  occupy 
our  attention  for  some  time.  For  a  more  exhaustive  account  of  joint 
diseases,  I  refer  you  especially  to  the  excellent  works  of  Bonnet^  Vblk 
mann,  and  Sueter. 


CHRONIC   INFLAMMATION   OF   THE   JOINTS.  555 

A     THE  FUNGOUS  AND  SUPPUEATIVE  AETICULAR   INFLAMMATIONS. 

(TUMOE  ALBUS). 

Tumor  albus  (white  swelling)  is  an  old  name  which  was  formerly 
applied  to  almost  all  swellings  of  the  joints  that  ran  their  course  with- 
out redness  of  the  skin ;  now  it  has  been  agreed  only  to  give  this  name 
to  the  affection  we  are  about  to  describe,  which  is  also,  with  more  or 
less  correctness,  termed  scrofulous  wflammation  of  the  joint ;  but  of 
this  later. 

The  disease  is  very  frequent  in  childhood,  particularly  in  the  hip 
and  knee  joints ;  it  usually  begins  very  insidiously,  more  rarely  sub- 
acutely.  If  the  knee-joint  be  affected,  the  parents  usually  first  notice 
a  slight  dragging  or  limping  of  the  lame  leg  ;  the  child,  either  volun- 
tarily or  on  questioning,  complains  of  pain  after  walking  some  dis- 
tance, and  on  pressure  over  the  joint ;  about  the  knee  itself  the  laity 
can  see  nothing  out  of  the  way.  On  comparing  both  knees,  the  sur- 
geon will  find,  even  quite  early  in  the  disease,  that  the  two  furrows 
which  normally  run  alongside  of  the  patella,  when  the  limb  is  ex- 
tended, and  give  the  knee-joint  its  shapeUness,  have  either  disappeared 
on  the  affected  side  or  at  least  are  shallower  than  on  the  sound  side  ; 
except  this  there  is  nothing  observable.  The  hinderance  to  walking  is 
so  slight  that  children  go  about  with  a  slight  Hmp  for  months,  and 
complain  so  little  that  it  is  some  time  before  the  parents  feel  obliged 
to  consult  a  surgeon ;  they  often  delay  doing  this  till,  after  continued 
exertion,  the  limb  has  begvui  to  pain  and  swell  more.  The  swelling, 
wliich  was  at  first  scarcely  perceptible,  is  now  quite  evident ;  the 
knee-joint  appears  evenly  round  and  quite  sensitive  to  pressvire.  If 
we  suppose  that  no  treatment  be  instituted,  but  the  disease  left  to 
itself,  its  course  is  about  as  follows :  The  patient  continues  to  limp 
around  for  a  few  months,  but  finally  the  time  comes  when  he  cannot 
walk ;  he  is  obliged  to  lie  down  most  of  the  time,  because  the  joint  is 
so  painful ;  gradually  it  becomes  more  and  more  angular,  especially 
after  each  subacute  exacerbation.  Now,  certain  parts  of  the  joint,  at 
the  inner  or  outer  side,  or  in  the  hollow  of  the  knee,  become  more 
painful ;  there  is  evident  fluctuation  at  some  one  of  these  points  ;  the 
skin  grows  red,  and  finally  suppurates  from  within  outward,  and  is 
perforated  after  a  few  months  ;  a  thin  pus,  mixed  with  fibrinous  cheesy 
flocculi,  escapes.  Now  the  pain  decreases,  the  condition  improves ; 
but  this  improvement  does  not  last  long ;  a  new  abscess  soon  forms, 
and  so  it  goes  on.  Meantime,  perhaps  two  or  three  years  have 
elapsed,  the  general  health  of  the  patient  has  suffered;  the  child, 
which  was  previously  strong  and  healthy,  is  now  pale  and  thin  ;  the 
opening  of  the  abscesses  is  not  unfrequently  accompanied  or  followed 
by  fever ;  this  fever  exacerbates  as  each  new  abscess  develops ;  this 


556  TUMOR  ALBUS. 

exhausts  the  patient ;  he  loses  his  appetite,  digestion  is  impaired, 
diarrhoea  comes  on,  and  the  emaciation  is  increased  from  week  to 
week.  Even  at  this  period  the  disease  may  spontaneously  subside, 
although  this  rarely  happens ;  more  frequently  it  proves  fatal,  from 
the  exhaustion  caused  by  the  suppuration  and  continued  hectic  fever. 
Should  recovery  take  place,  it  is  announced  by  decrease  of  the  sup- 
puration, retraction  of  the  fistulous  openings,  improvement  of  the 
general  health,  increased  appetite,  etc. ;  finally,  the  fistulas  heal,  the 
joint  remains  angular  or  distorted  in  some  way,  the  pain  ceases,  and 
the  patient  escapes  with  his  life  and  a  stiff  leg ;  this  termination  of 
chronic  suppuration  of  the  joint  in  anchylosis  (stifiF-joint)  is  the  most 
favorable  that  can  occur  when  the  disease  has  been  severe  ;  the  anchy- 
losis may  be  complete  or  imperfect,  i.  e.,  the  joint  may  be  perfectly 
stiff  or  slightly  movable;  the  whole  process  may  have  lasted  from 
two  to  four  years. 

Among  the  local  symptoms  I  may  add  that  for  each  joint  certain 
muscles  gradually  become  permanently  contracted  ;  usually  it  is  the 
flexors  ;  in  the  hip-joint  the  adductors  and  rotators  are  also  affected, 
and  the  joint  is  permanently  held  in  such  a  position  as  to  give  little 
or  no  pain.  If  these  pathological  positions  are  caused  by  the  mus- 
cular contraction  alone,  and  have  not  continued  too  long,  they  may 
at  once  be  overcome  by  anaesthesia.  But  after  months  or  years 
atrophy  begins  in  the  fasciae,  and  afterward  in  the  muscles,  which 
even  under  anaesthetics  can  only  be  broken  up  by  force.  After  long 
disuse  the  muscles  are  greatly  atrophied  by  fatty  degeneration  and 
cicatricial  contraction.  The  articular  capsule  too,  which  was  much 
infiltrated  and  swollen,  as  well  as  the  accessory  ligaments,  also  con- 
tract on  the  side  toward  which  the  joint  has  been  bent  ;  thus,  in  the 
case  of  the  knee-joint  this  contraction  would  be  greatest  in  the  hol- 
low of  the  knee. 

Cases  where  the  disease  begins  with  a  seropurulent  effusion  in 
the  joint  (catarrhal,  blennorrhceal  synovitis)  are  rare,  I  have  seen 
them  chiefly  in  tuberculous  patients.  The  symptoms  are  at  first  the 
same  as  in  chronic  dropsy  of  the  joint,  but  the  joint  is  painful  and 
its  function  more  impaired.  Comparatively  often  ostitis  and  perios- 
titis near  a  joint  are  the  causes  of  synovitis  ;  one  or  other  side  of 
the  condyles  of  the  femur,  tibia,  or  humerus,  or  the  posterior  sur- 
face of  the  olecranon,  become  painful  ;  the  pain  remains  localized 
for  some  time  at  one  point ;  then  there  is  a  doughy  oedema,  and 
finally  an  abscess.  Meantime  the  functions  of  the  joint  may  remain 
unimpaired  for  months,  till  the  suppuration  (occasionally  with  acute 
inflammatory  symptoms)  attacks  the  joints  ;  then  the  course  above 
described  begins.    In  some  cases  these  abscesses  always  remain  peri- 


CHRONIC  INFLAMMATION  OF  THE  JOINTS.  657 

articular,  and  heal  before  the  joint  is  opened  ;  this  might  cause  peri- 
articular cicatricial  contraction,  while  the  joint  was  perfectly  healthy. 

["  As  the  disorder  advances,  the  alterations  become  more  dis- 
tinctly defined,  for,  as  the  disorganizing  process  is  now  in  full  play, 
its  devastating  effects  are  plainly  visible  in  every  portion  of  the 
joint.  The  lymph  increases  in  quantity,  and  is  often  intermixed 
Avith  sero-purulent  matter,  or  thick,  greenish-looking  pus.  The  tufts 
of  the  synovial  membrane  are  converted  into  soft,  gelatinous,  fun- 
gous granulations,  which  gradually  cover  the  cartilage,  extend  into 
and  finally  destroy  it,  imparting  to  it  an  ulcerated  or  worm-eaten 
appearance.  The  bony  structure  is  finally  invaded  by  the  granula- 
tions, rendering  it  very  red,  soft,  carious,  rough,  and  easily  crum- 
bled. The  ligaments  exhibit  well-marked  signs  of  inflammation, 
being  loose  and  spongy  at  one  point,  attenuated  at  another,  and 
perhaps  thickened  or  hypertrophied  at  a  third."] 

Lastly,  the  bones  may  be  primarily  attacked  by  ostitis  malacis- 
sans  ;  this  occurs  particularly  in  the  carpus,  tarsus,  and  caput 
femoris  of  feeble  patients  ;  the  joints  may  long  remain  unaffected, 
even  if  periosteal  abscesses  with  great  oedema  and  suppurating 
fistulas  form.  In  primary  diseases  outside  of  the  epiphyses  mus- 
cular contractions  are  less  apt  to  develop  than  in  primary  disease 
of  the  synovial  membrane  and  primary  subchondral  ostitis. 

This  short  description  may  serve  you  for  a  general  type  of  the 
disease  in  question,  and  of  its  importance;  to  enable  you  to  under- 
stand the  various  forms  in  which  it  may  appear,  it  seems  advisable  to 
first  give  you  a  clear  description  of  the  anatomical  changes  in  these 
diseases  of  the  joint.  We  have  the  opportunity  of  observing  the  dif- 
ferent stages  of  these  changes  in  exsected  joints,  in  amputated  limbs, 
and  on  the  dead  body.  I  have  paid  so  much  attention  to  this  subject, 
that  from  my  individual  observations  I  can  give  you  a  very  accurate 
account  of  the  anatomical  changes.  These  are  much  alike  in  all  cases, 
and,  from  what  you  already  know  about  chronic  inflammations  of  other 
parts,  you  will  anticipate  that  there  is  in  reality  only  a  variation  of  the 
old  story  of  serous  and  plastic  infiltration  with  various  grades  of  vas- 
cularization, of  proliferation,  and  destruction,  etc. 

Let  us  first  with  the  naked  eye  study  these  joints  in  various  stages 
of  the  disease.  Let  us  suppose  the  common  case  of  the  affection  be- 
ginning with  chronic  synovitis :  we  first  find  swelling  and  redness  of 
the  synovial  membrane ;  it  has  already  undergone  some  change  in  the 
lateral  portions  of  the  joint,  in  the  folds,  and  neighboring  sacs ;  its 
tufts  are  puffed  up,  very  little  elongated,  but  very  soft  and  succulent ; 
the  whole  membrane  is  more  readily  distinguished  from  the  firm  tissues 
of  the  capsule,  and  may  be  detached  with  greater  facility  than  normal 


558 


CHRONIC  INFLAMMATION   OF   THE   JOINTS. 


ly.  At  tliis  time  the  synovia  is  rarely  increased,  but  is  cloudy,  or  even 
resembles  muco-pus.  These  changes  in  the  synovial  membrane  gradu- 
ally increase;  it  becomes  thicker,  more  oedematous,  softer,  redder;  the 
tufts  grow  to  thick  pads,  and  in  places  resemble  spongy  granulations. 
The  surface  of  the  cartilage  loses  its  blue  lustre,  though  it  is  not  yet 
visibly  diseased ;  but  the  synovial  outgrowths  begin  to  grow  over  the 
cartilages  from  the  sides,  and  to  push  in  between  the  two  adjacent 
surfaces  of  cartilage ;  meantime  the  capsule  of  the  joint  is  also  thick- 
ened, and  has  acquired  an  evenly,  fatty  appearance,  and  is  very  oedema- 
tous ;  this  swelling  and  oedema  gradually  extend  to  the  subcutaneous 
tissue,  and  to  the  skin.  From  this  point,  the  changes  iu  the  cartilage 
claim  most  of  our  attention.  The  synovial  proliferations,  in  the  shape 
of  red  granular  masses,  advance  gradually  over  the  entire  surface  of 
the  cartilage,  and  cover  it  completely,  lying  over  it  like  a  veil  (Fig.  93) ; 


Fio.  93. 


Diagram  of  a  eection  of  a  knee-joint  (the  intcrarticnlar  cartilajres  have  heen  left  ont,  the  ar- 
ticular cartilages  shaded)  with  fungous  inflammation:  a  a,  fibrous  capsule  ;  b,  cnicial  liga- 
ment; c,  femur;  d.  tibia;  ee,  fungous  synovial  membrane  growing  into  the  cartilage,  at/ it 
even  grows  into  the  bone;  at  ff  are  isolated  proliflcationB  of  the  granulations  into  the 
bone  on  the  border  between  bone  and  cartilage. 


if  we  attempt  to  remove  this  veil,  we  hnd  that  in  some  places  it  is 
attached  quite  firmly  by  processes  entering  the  cartilage,  just  as  the 
roots  of  an  i\y-vine  cling  to  and  insert  themselves  into  the  wall 
against  which  it  grows  (as  is  also  the  case  in  pannus  of  the  cornea) ; 
these  roots  not  only  elongate,  they  spread  out,  and  gradually  eat  up 
the  cartilage,  which,  when  the  covering  of  fungous  prolifications  is  re- 
moved, appear  first  rough  here  and  there,  then  perforated,  and  finally 
disappear  altogether ;  then  the  fungous  prolification  extends  into  the 
bone,  and  commences  to  consume  this ;  the  result  is  fungous  caries,  as 


TUMOR  ALBUS.  559 

we  have  already  learned;  as  a  result  of  the  changes  from  chronio 
inflammation,  the  bone  is  destroyed  in  the  manner  before  described, 
and  here  you  have  the  whole  course  and  the  relation  of  fungous  m- 
flammation  of  the  joint  to  caries.  The  morbid  process  advances  un- 
equally ;  one  condyle  of  a  joint  may  be  almost  consumed  while  another 
partly  preserves  its  cartilaginous  surface.  The  other  parts  of  the  sy- 
no\dal  membrane  may  also  proliferate  outwardly  toward  the  capsule ; 
capsule,  subcellular  tissue,  and  skin,  are  transformed  at  one  place  or 
another  into  fungous  granulations,  wdth  or  without  suppuration,  and 
thus  we  have  external  openings,  and  fistute,  which  either  communicate 
directly  with  the  joint,  or  with  a  synovial  sac. 

Here  let  us  stop  a  moment  to  notice  what  may  be  seen  with  the 
microscope  at  the  affected  part;  on  this  point  I  can  give  you  least 
that  is  new.  The  normal  synovial  membrane  consists  of  loose  con- 
nective tissue  with  moderately  rich  capillary  net-work,  which  forms 
complicated  folds  in  the  tufts ;  on  the  surface  of  the  membrane  there 
is  a  simple  layer  of  endothelium,  composed  of  flat  polygonal  cells,  just 
as  there  is  on  most  serous  membranes.  The  tissue  of  the  membrane 
is  gradually  permeated  with  cells,  becomes  softer,  loses  its  firm,  fibrous 
character,  and  the  vessels  dilate  and  increase  decidedly.  The  en- 
dothelium is  destroyed  in  limited  layers  of  flat  scales ;  its  place  is  sup- 
plied by  small,  round,  newly-formed  cells,  which  soon  unite  with  the 
constantly-degenerating  tissue  of  the  synovial  membrane,  and  cease 
to  be  distinguishable  as  separate  layers.  Through  the  progress  of  the 
plastic  infiltration  the  synovial  membrane  gradually  loses  its  former 
structure ;  the  connective  tissue,  filled  with  innumerable  new  cells, 
gradually  becomes  homogeneous,  and  from  the  constantly-increasing 
vascularization  the  tissue  histologically  exactly  resembles  that  of  gran- 
ulations. In  these  spongy  granulations  small  white  nodules  form 
here  and  there  ;  these  are  sometimes  like  mucous  tissue,  sometimes 
they  are  composed  chiefly  of  pus-cells  and  even  giant-cells. 

[The  tuberculous  nature  of  the  nodules  found  in  white  swelling 
has  long  been  disputed  :  here,  as  in  other  pathological  products 
whose  origin  is  doubtful,  inoculation  has  been  tried  ;  and  Konig,  by 
inoculating  some  of  the  fungous  proliferations  of  joints,  has  induced 
miliary  tuberculosis,  while  Ilueter  introduced  isolated  nodules  from 
a  synovitis  fuugosa  into  the  anterior  chamber  of  the  eye  of  a  rabbit, 
and  this  was  followed  by  choroidal  tubercle,  and  after  a  long  period 
of  incubation  by  general  tuberculosis.  These  experiments  have 
been  repeated  by  many  pathologists  and  surgeons,  and  there  can  be 
no  doubt  that  most  cases  of  so-called  granular  or  fungous  synovitis 
are  of  tubercular  nature.  On  the  other  hand,  it  is  certain  that  in 
some  persons,  at  least,  tuberculosis  of  the  joints  is  a  primary  disease, 


660 


CHRONIC   INFLAMMATION   OF   THE   JOINTS. 


and  for  a  long  time  remains  local,  so  that  on  autopsy  the  only  tu- 
berculous point  found  is  in  the  joint.  The  question,  "  How  does  the 
tuberculous  virus  reach  the  synovial  membrane  ?  "  is  just  as  difficult 
of  sohitioB  as  in  the  case  of  primary  tuberculosis  of  the  bones.  It 
has  long  been  known  that  injuries  of  the  joints,  especially  con- 
tusions, sprains,  intra-articular  haemorrhages,  etc.,  often  excite  the 
disease  ;  but  this  does  not  explain  how  these  subcutaneous  injuries, 
to  which  the  extravasation  is  the  only  thing  in  common,  should  cause 
the  entrance  of  tuberculous  virus.  Cohnheim  thinks  that  in  these 
cases  also  the  infection  comes  through  the  lungs  or  intestines,  and 
then  the  virus  circulates  in  the  blood,  perhaps  with  the  corpuscles, 
and  escapes  at  the  point  of  injury  through  the  vessels  which  have 
become  permeable  from  the  traumatic  inflammation,  or  in  the  blood 
which  has  been  extravasated  into  the  tissue.  M.  Schi'dler's  experi- 
ments have  shown  the  possibility  of  inducing  fungous  inflammation 
of  the  joints  by  very  slight  injuries  in  animals  that  have  been  made 
tuberculous  by  inhalations.  The  significance  of  fungous  synovitis, 
ostitis,  periostitis,  etc.,  termed  local  tuberculosis,  is  that  at  any  time 
they  may  induce  general  tuberculosis.] 


Fig.  94. 


Degeneration  of  the  cartilage  in  fnnfrons  inflammation  of  the  Joint,    a,  Granolation-tiecue  oO 
the  surface,  magnified  350  diameters ;  after  0.  Weber. 


But  in  cartilage  there  are  also  occasionally  appearances  which 
show  that  sometimes  the  cartilage-cells  participate  little  in  the  cell- 
proliferation,  so  that  there  may  also  be  a  more  passive  absorption  of 
the  cartilage-substance  from  proliferation  of  the  synovial  membrane. 
The  histological  changes  in  the  articular  capsule  and  ligaments  con- 
sist in  serous  and  plastic  infiltration  which  only  attain  a  high  grade 
at  certain  points,  but  generally  only  induce  connective-tissue  neo- 
plasiae,  which  to  the  naked  eye  resemble  fatty  thickenings. 


TUMOR  ALDUS. 


561 


Now  that  you  have  a  general  view  of  the  anatomical  changes  in 
fungous  inflammation  of  the  joints,  we  may  go  more  minutely  into 
the  various  modifications ;  in  so  doing  we  shall  start  from  the  above- 
described  course.  So  far  I  have  represented  the  course  of  the  dis- 
ease as  it  occurs  when  originating  in  the  synovial  membrane,  but 
there  are  also  other  starting-points  for  the  disease ;  there  may  be  a 
central,  or  more  rarely  a  peripheral,  caries  in  the  spongy  epiphysis  of 
a  hollow  bone,  or  in  one  of  the  spongy  bones  of  the  wrist  or  ankle, 
and  this  may  perforate  from  Avithin  outwardly  through  the  cartilage, 
and  thus  excite  synovitis.  It  also  happens  that,  sometimes,  along  with 
the  fungous  proliferation  of  the  synovial  membrane,  there  is  an  inde 
pendent  proliferation  under  the  cartilage,  in  the  boundary  between  it 
and  the  bone  (Fig.  93,  g)^  which  subsequently  unites  with  that  from 
above,  so  that  the  cartilage  lies  partly  movable  between  the  two 
granular  layers.  This  occurs  quite  frequently,  especially  in  the  hip, 
elbow,  and  ankles.  The  cartilage  is  so  loosened  by  this  primary  osti- 
tis of  the  ends  of  the  bone  or  sub-chondral  caries,  that  it  may  be  re- 
moved apparently  intact  from  the  subjacent,  vascvilar,  soft  bone.  It 
has  already  been  mentioned  that  inflammation  of  a  joint  may  be  in- 
duced by  acute  periostitis  and  osteomyelitis  ;  the  inflammation  then 
extends  from  the  periosteum  to  the  capsule  of  the  joint,  and  thence  to 
the  synovial  membrane ;  the  anatomical  changes  are  as  above  de- 
Fig.  95. 


Subchondral  caries  of  the  astrasralns.  Perforation  of  the  proliferating  granulations  into  the 
joint;  magnified  twenty  diameters:  a,  cartilage;  6,  granulations ;  c,  normal  bone,  with 
medulla. 


scribed.  The  infiltrations  which  we  so  often  find  around  the  sheaths 
of  the  tendons  on  the  dorsum  of  the  foot  are  often  independent 
diseases  of  the  cellular  tissue  of  the  periosteum  and  sheath  of  the 
tendon,  but  frequently  they  are  due  to  ostitis  of  the  ankle- 
bones.  When  an  acute  traumatic  inflammation  of  a  joint  or  an 
idiopathic  acute  suppurative  synovitis  passes  into  the  chronic  stage, 
37 


562  CHRONIC  INFLAMMATION  OF  THE  JOINTS. 

the  same  anatomical  changes  go  on  as  in  fungous  inflammation. 
Chronic  periostitis  in  the  vicinity  of  the  joint  may  also  cause  inflam- 
mation of  the  joint,  especially  when  it  induces  cold  abscesses ;  as  may 
also  chronic  granular  proHferations  in  the  capsule,  remains  of  neg- 
lected sprains  of  the  joint. 

The  external  appearance  especially  is  greatly  influenced  by  the 
extent  to  which  the  parts  immediately  around  the  joint  participate  in 
the  inflammation ;  if  tlie  capsule  participate  very  actively,  the  joint 
becomes  regularly  thick  and  round.  This  enlargement  of  the  joint 
is  also  considerably  increased  by  the  formation  of  osteophytes,  which 
form  on  the  articular  surfaces ;  these  will  be  the  larger,  the  more  the 
capsule  and  periosteum  of  the  articular  surfaces  have  been  implicated, 
and  the  more  proliferating  and  productive  the  disease  generally ; 
while  from  the  joint  the  condyles  and  sesamoid  bones  are  destroyed, 
from  without  new  bone  is  formed  as  described  to  you  under  caries. 
Caries  of  the  joint  has  an  old  name,  which  is  still  occasionally  used, 
it  is  arthrocace  y  this  word  is  combined  with  the  name  of  the  different 
joints,  and  thus  we  speak  of  gonarthrocace,  coxarthrocace,  omar- 
throcace,  etc.  Jxicst  wrote  a  book  about  diseases  of  the  joint,  and 
gave  it  the  fearful  name  "  arthrocacologie,"  which  it  is  not  worth 
your  while  to  remember  ;  I  only  mention  it  as  a  curiosity  ;  it  originated 
at  a  time  when  the  study  of  eye-diseases  also  consisted  almost  exclu- 
sively in  learning  by  heart  the  most  frightful  Greek  names.  The  ex- 
tent to  which  the  muscles  suffer  in  tumor  albus  is  imiDortant.  In  the 
vicinity  of  the  inflamed  joint,  and  often  some  distance  from  it,  the 
contractile  substance  in  the  primitive  filaments  gradually  disappears, 
usually  after  precedent  fatty  degeneration,  and  the  affected  limb 
atrophies  more  and  more,  in  some  patients  more  than  in  others ;  the 
thinner  it  becomes,  the  more  striking  grows  the  enlargement  of  the 
joint,  which  often  is  not  really  very  decided  when  you  compare  its 
measurement  with  that  of  the  sound  one.  You  will  occasionally  hear 
and  read  of  the  puffing  up  and  enlargement  of  the  articular  ends  of 
the  bones  in  tumor  albus ;  this  is  a  false  expression  ;  in  caries  of  the 
joint  the  bones  never  swell ;  when  they  appear  swollen,  the  swelling 
is  due  to  the  thickening  of  the  soft  parts  or  to  formation  of  osteo- 
phytes. 

A  further  difference  in  the  course  of  diseases  of  the  joints  lies  in 
the  greater  or  less  tendency  to  suppuration;  abscesses  and  fistulae  are 
by  no  means  necessary  sequelae  of  fungous  inflammations  of  the 
joints,  they  are  rather  accidents.  You  already  know  that  caries  fun- 
gosa  not  unfrequently  runs  its  course  without  suppuration.  The  fun- 
gous articular  inflammations  are  often  accompanied  by  caries  sicca ;  the 
affection  may  go  on  for  years  without  the  formation   of  abscesses,  es- 


TUMOR  ALBUS.  563 

pecially  in  adults  otherwise  healthy ;  there  may  be  extensive  destruc- 
tion of  the  cartilages  and  bones,  with  the  consecutive  dislocations  al- 
ready mentioned  vmder  caries,  without  a  drop  of  pus.  If,  in  such  a 
case  of  so-called  caries  sicca,  you  examine  the  granulations  in  the 
joint  and  bone,  you  will  find  them  firmer  than  usual,  and  occasionally 
of  almost  cartilaginous  consistence,  like  granulations  that  are  about 
to  atrophy  or  cicatrize ;  indeed,  they  do  partly  atrophy,  but  the  pro- 
liferation often  goes  on  again,  and  the  bone  is  destroyed ;  the  pro- 
cess is  thus  analogous  to  cirrhosis.  Hence  suppuration  is  by  no  means 
a  measure  for  the  extension  of  the  process  in  the  bone ;  on  the  con- 
trary, the  more  luxurious  the  proliferation  of  the  granulations,  the 
more  extensive  the  destruction.  The  dislocation  of  the  bones,  the 
deformity  of  the  joint,  is  the  most  imjDortant  measure  of  the  extent  of 
the  changes  in  the  bones  and  ligaments ;  if  in  a  case  of  diseased  knee 
the  leg  begins  to  rotate  outwardly,  and  the  tibia  to  shove  backward, 
there  is  certainly  destruction  of  part  of  the  bone,  and  of  a  large  part 
of  the  ligaments  of  the  joint.  In  many  cases  fungous  inflammation 
of  the  joint  is  accompanied  by  suppuration ;  the  pus  is  produced 
either  by  the  granulations,  or  else  forms  on  the  surface  of  the  syno- 
vial sac  which  is  not  much  diseased ;  sometimes  in  the  same  sao 
there  is  a  subacute  synovitis,  while-  another  part  of  the  sac  remains 
intact,  and  still  another  is  completely  degenerated ;  the  knee  and  el- 
bow joints  are  especially  liable  to  these  circumscribed  separate  dis- 
eases of  individual  synovial  sacs,  which  only  communicate  with  the 
cavity  of  the  joint  by  small  openings.  These  suppurations  are  usu- 
ally accompanied  by  acute  exacerbations  of  pain  and  fever,  especially 
when  the  abscess  opens  externally,  and  syno\'ial  sacs,  which  have  pre- 
viously participated  little  in  the  inflammation,  suddenly  become 
acutely  or  subacutely  diseased.  An  early  profuse  suppuration  of  a 
joint  is  sometimes  an  evidence  of  the  previously  slight  degeneration 
of  the  synovial  membrane,  as  most  pus  is  given  out  by  serous  mem- 
branes in  the  stage  of  purulent  catarrh.  The  pus  from  the  synovial 
granulations  is  usually  of  slight  amount,  and  of  serous  or  mucous  con- 
sistence. The  symptoms  may  be  difierent,  if,  as  often  happens, 
there  be  also  suppuration  in  the  cellular  tissue  around  the  joint,  and 
periarticular  abscesses  (which,  indeed,  may  occur  without  disease  of 
the  joints)  accompany  the  fungous  inflammation  of  the  joints.  All 
of  these  suppurations  are  important,  from  the  fact  that  they  impair  the 
general  health,  partly  by  the  loss  of  juices,  partly  by  the  fever. 

Lastly,  we  must  give  some  attention  to  the  vital  condition  of  the 
inflammatory  neoplasia.  The  vitality,  the  luxuriance  of  growth,  and 
the  future  fate  of  the  chronic  inflammatory  new  formations,  greatly  de- 
pend, as  you  already  know,  on  the  general  constitutional  condition  of 


564 


CHRONIC  INFLAMMATION   OF   THE   JOINTS. 


the  patient ;  in  fact,  this  is  so  to  such  an  extent  that  from  the  vita) 
condition  of  the  local  affection  we  may  often  make  a  decision  as  to 
the  general  health  of  the  patient.  Fungous  inflammation  of  the  joint 
with  caries  sicca,  and  a  disposition  to  cicatricial  contraction  of  the 
new  formation,  usually  occurs  in  persons  otherwise  healthy,  and  in 
these  cases  it  is  often  difficult  to  find  any  cause  for  the  chronicity  of 
the  disease,  which  was  said  to  have  been  first  induced  by  cold,  fa- 
tigue, or  injury  of  some  sort.  We  also  find  the  most  luxuriant, 
spongy  granulations  and  secretion  of  muco-pus  in  tolerably  healthy, 
or  at  least  well-nourished  persons,  in  fat,  scrofulous  children,  also  as 
the  chronic  continuation  of  an  acute  articular  inflammation  in  per- 
sons previously  healthy,  who  have  become  anaemic  from  the  long  sup- 
puration. Great  tendency  of  the  neoplasia  to  break  dowm  into  pus, 
or  to  molecular  disintegration,  is  usually  a  sign  of  bad  nutrition  ; 
we  find  thin,  badly-smelling  pus  in  large  amounts,  with  excessive  ul- 
ceration of  the  skin,  and  fistulous  openings,  that  look  as  if  cut  out 
with  a  punch,  in  the  articular  inflammation,  with  or  without  caries, 
of  old  cachectic  patients,  in  badly-nourished  tuberculous  subjects  and 
scrofulous  children.  Here  we  may  have  the  same  course  of  affairs  as 
in  torpid  caries ;  the  neoplasm  is  very  short  lived,  it  breaks  down  al- 
most as  soon  as  formed  ;  and  along  with  the  caries  we  have  necrosis, 
as  in  the  small  bones  of  the  wrist,  more  rarely  in  the  epiphyses,  also 
caseous  degeneration  of  the  neoplasm. 

Fio.  98. 


Atonic  ulceration  of  the  cartilage  from  the  knee-joint  of  a  child ;  the  cartilage-cells,  which  only 
proliferate  slightly,  undergo  fat.ty_  degeneration,  and  they,  with  the  intercellular  Bubstauce, 
break  down  very  rapidly.    Magnified  250  diameters. 

We  could  distinctly  separate  this  atonic  form  of  chronic  suppura- 
tive inflammation  of  the  joint  from  the  fungous  variety,  but  avoid 
doing  so  :  first,  that  we  may  not  disturb  the  general  description ;  sec- 
ondly, because  this  form  also  often  begins  as  a  typical  fungous  syno- 
vitis, and  subsequently  passes  into  the  torpid  form  as  the  nutritive 
state  of  the  patient  declines.  We  find  it  chiefly  on  autopsy,  and 
should  altogether  mistake  the  earlier  stages  if  we  did  not  study  the 
disease  in  resected  and  amputated  joints.  I  shall  not  continue  the 
anatomical  details,  which  might  be  carried  much  further,  but  what  has 


TUMOR  ALBUS.  565 

already  been  said  will  suffice  to  explain  to  you  any  given  case.  It  is 
not  impossible  to  group  the  different  modifications  of  the  above  pro- 
cesses in  classes  and  to  analyze  them  separately ;  but  this  seems  to 
me  of  no  practical  value,  for  these  forms  offer  at  present  no  special 
etiological,  prognostic,  or  therapeutic  features.  If  you  correctly  un- 
derstand the  anatomical  course  and  recall  my  description  in  all  cases 
that  you  see  living  or  dead,  in  resected  or  amputated  limbs,  you  will 
soon  understand  the  disease  and  require  no  further  classification  of 
its  symptoms. 

About  the  causes  of  chronic  fungous  articular  inflammation  there 
is  little  to  say  beyond  what  you  already  know.  The  scrofulous  diath- 
esis especially  predisposes  to  it ;  acute,  spontaneous,  or  traumatic 
(whether  from  wounds,  contusions,  or  sprains)  inflammations  of  the 
joint  occasionally  become  chronic.  Scrofulous  children,  three  years 
old  and  upward,  are  especially  inclined  to  these  joint-diseases ;  a  fall 
or  twisting  of  the  joint  often  proves  an  exciting  cause.  Cases  occur 
where  we  can  find  no  local  or  general  cause  for  the  disease.  In  Swit- 
zerland I  have  very  often  seen  atonic  forms  of  fungous  purulent  in- 
flammations of  the  joint  in  old  people,  where  no  cause  for  them  could 
be  discovered. 

The  course  of  this  disease  is  very  varied,  but  it  is  always  chronic, 
lasting  for  months,  usually  for  years ;  often  interrupted  by  pauses 
and  improvement,  then  again  exacerbating.  The  disease  may  halt, 
and  recover  at  any  stage ;  in  the  first  stages  this  recovery  may  be  per- 
fect, that  is,  the  joint  may  remain  entirely  movable ;  or  it  may  be  im- 
perfect, that  is,  more  or  less  stiflFness  of  the  joint  is  left.  Before  the 
cartilage  has  commenced  to  proliferate,  or  has  its  under  siu-face  dis- 
turbed by,  any  neoplastic  tissue  growing  from  the  bone,  there  is  a 
possibility  of  tolerably  good  motion  being  restored — which,  however, 
may  be  impaired  by  cicatricial  contraction  of  the  fungous  synovial 
membrane,  and  of  the  infiltrated  ligaments,  as  well  as  by  secondary 
contractions  of  the  muscles.  If  the  cartilage  be  partly  or  entirely 
destroyed,  and  caries  has  occurred  gradually  or  with  the  onset  of  the 
disease,  it  may  recover  with  anchylosis,  the  cartilage  is  not  restored ; 
the  granulations  of  the  adjacent  surfaces  of  cartilage  gradually  unite, 
and  often  firm  adhesions  form,  which  may  even  ossify.  AVhether  the 
disease  goes  on  so  far  or  the  destruction  of  the  joint  continues  to 
progress,  depends  greatly  on  the  constitution  of  the  patient ;  treatment 
may  be  of  great  benefit,  if  begun  early.  The  extent  to  which  the 
muscles  sympathize  varies  greatly ;  according  to  my  experience,  the 
highest  grade  of  muscular  atrophy  occurs  in  those  cases  w^here  there 
is  no  suppuration  of  the  joints  but  caries  sicca,  and  where  the  joint 
disease  seems  to  proceed  from  ostitis. 


566  CHRONIC   INFLAMMATION   OF   THE   JOINTS. 

Now  for  a  sliort  discussion  of  certain  symptoms.  Each  form  of  this 
disease  may  run  its  course  with  more  or  less  pain ;  the  cause  of  this 
I  am  unable  to  explain  ;  there  are  cases  where  the  bone  is  extensively 
destroyed,  without  any  pain,  others  where  it  is  very  severe  ;  the  acute 
exacerbations  with  development  of  new  abscesses  are  always  rather 
painful — on  probing  the  fistulas  we  sometimes  find  bone,  at  other 
times  not ;  whether  we  feel  it  or  not,  depends  on  whether  it  is  covered 
with  granulations  or  lies  exposed ;  the  same  is  true  of  friction  ;  crep- 
itation is  only  valuable  as  a  sign  of  caries  of  the  articular  extremi- 
ties, when  it  exists ;  if  it  fail  in  the  later  stages,  it  is  no  proof  that 
the  bone  is  not  diseased.  The  deformity,  the  displacement  of  the 
articular  surfaces,  pathological  or  spontaneous  luxations,  are  the  only 
evidence  at  all  certain  of  the  extent  of  the  destruction  of  the  bone  ; 
here  we  can  only  be  deceived  when  the  capsule  has  ruptured  early, 
and  the  head  of  the  bone  is  actually  luxated ;  a  rare  case,  which  has, 
however,  been  seen  in  the  hip,  and  might  possibly  occur  in  the  shoulder. 
In  regard  to  judging  of  the  anatomical  condition  of  the  joint,  little  can 
be  added  to  what  has  already  been  said,  but  we  have  some  assistance 
from  the  etiology  and  duration  of  the  complaint.  Profuse  suppuration 
from  the  joint  is  always  a  sign  that  part  of  the  synovial  membrane 
has  not  yet  been  destroyed,  or  that  there  are  large  abscesses  near  the 
joint;  the  secretion  from  fungous  granulations  is  less  abundant,  serous 
or  mucous.  We  have  no  certain  evidences  of  the  extent  to  which  the 
cartilage  is  destroyed.  To  add  any  thing  about  the  diagnosis  and 
prognosis  would  only  be  to  repeat  Avhat  has  already  been  said,  from 
which  you  have  all  the  data  for  forming  your  judgment.  From  my 
own  experience,  I  think  I  may  say  that  slight  swelling  of  the  joint, 
with  great  pain  and  early  muscular  atrophy  in  anaemic  children,  but 
with  little  or  no  supj^uration,  indicates  primary  disease  of  the  bone, 
and  renders  the  prognosis  very  bad.  A  good  nutritive  condition  is 
the  most  important  point  for  a  favorable  prognosis,  which  would  not 
be  very  greatly  affected  even  by  early  and  extensive  suppuration. 


TREATMENT.  667 


LECTURE    XXXVIII. 

Treatment  of  Tumor  Albus. — Operations. — Resection  of  tlie  Joints. — Criticisms  on  the 
Operations  on  ttie  Different  Joints. 

Now  let  us  take  up- the  subject  of  treatment.  As  in  all  clironic 
inflammations,  this  must  be  both  general  and  local,  and  the  general 
treatment  should  be  the  more  prominent,  the  more  chronic  and  in- 
sidious the  disease  ;  it  is  unnecessary  for  us  to  waste  words  over 
this  constitutional  treatment,  which  will  depend  on  the  peculiarities 
of  each  case  ;  you  already  know  its  outlines.  The  salient  points 
for  treatment  are,  the  nutritive  state  of  the  patient,  the  quality  of 
his  blood,  and  the  general  hygienic  and  dietetic  conditions  under 
which  he  lives.  It  is  your  duty  conscientiously  to  advise  your  pa- 
tient to  the  best  of  your  knowledge,  but  you  will  soon  find  that  on 
these  points  you  meet  the  greatest  indifference,  and  that  your  ad- 
vice will  rarely  be  followed.  The  worst  instances,  such  as  heredi- 
tary predisposition,  we  shall  not  be  able  to  affect  ;  for  we  can  never 
expect  to  choose  the  strongest  persons  out  of  healthy  families  for 
the  propagation  of  the  species,  and  to  forbid  marriage  to  feeble 
persons  from  sickly  families.  Regarding  the  local  treatment  and 
its  results,  we  may  say,  in  general  terms,  that  it  is  the  more  effec- 
tive the  more  acute  the  stage  ;  as  a  rule,  it  is  not  difficult  to  relieve 
subacute  exacerbations,  or  subacute  commencements  of  the  disease. 
In  these  cases  we  derive  great  benefit  from  the  already  oft-men- 
tioned remedies  :  strong  salve  of  nitrate  of  silver  (  3  j  to  3  j  of  lard), 
painting  with  tincture  of  iodine,  flying  blisters,  wet  compresses, 
gentle  compression  with  adhesive  plaster  ;  this  should  be  accom- 
panied by  absolute  rest  of  the  joint,  which  in  the  lower  extremities 
can  only  be  attained  by  continued  confinement  to  bed. 

As  yet  I  have  no  experience  of  the  value  of  massage  in  the  com- 
mencement of  tumor  albus  ;  it  should  be  used  with  great  care.  I 
cannot  help  thinking  that  massage  used  too  strongly  in  these  cases 
might  induce  suppuration  where  there  was  any  tendency  to  it  ;  so 
I  would  only  recommend  this  treatment  in  torpid  cases. 


568  CHKONIC  INFLAMMATION   OF  THE  JOINTS. 

[In  all  cases  if  we  do  not  apply  massage  to  the  diseased  joint  we 
may  to  the  muscles  of  the  limb  to  prevent  their  atrophying,  which 
y/ould  otherwise  result  from  continued  rest.] 

There  is  no  doubt  that  in  most  cases  of  commencing  and  pro- 
gressing diseases  of  the  joints  traction  is  more  efficacious  than 
plaster  bandages  ;  hence,  in  my  clinic  you  will  see  it  used  more  fre- 
quently ;  but  in  private  i^ractice  you  can  not  persuade  all  patients 
to  go  to  bed,  and,  moreover,  the  method  requii*es  such  careful  watch- 
ing from  the  surgeon  as  to  interfere  with  its  employment.  Taylor, 
an  ingenious  American  surgeon,  has  constructed  splints  for  the  lower 
extremity  by  which  traction  may  be  so  applied  as  to  free  the  joint 
from  pressure  and  enable  the  j^atient  to  go  about.  These  splints 
often  act  excellently,  but  they  are  difficult  to  make,  and  their  use 
requires  a  certain  experience  on  the  part  of  the  surgeon.  All  of 
these  mechanical  aids — plaster  dressings,  supports,  traction,  Tay- 
lor's splint,  etc. — require  continued  supervision  to  prevent  injury 
from  pressure  and  friction  and  from  displacement  of  the  apparatus. 
In  the  case  of  children  great  patience  and  perseverance  are  needed 
in  judging  whether  the  extension  is  enough  or  too  great,  to  accus- 
tom them  to  the  inconvenience  of  the  apparatus,  to  quiet  the  anx- 
iety of  the  parents  when  the  child  cries,  and  by  friendly  talk  or 
sober,  earnest  efforts  to  make  the  children  obedient  and  prevent 
their  loosening  the  apparatus.  This  treatment  can  rarely  be  thor- 
oughly carried  out  in  private  practice  ;  hence,  treatment  in  hos- 
pitals or  orthopedic  institutions  cannot  be  too  strongly  urged,  at 
least  until  the  chief  dangers  from  deformity  are  jjassed. 

With  such  a  dressing  we  may  permit  the  patient  to  go  about, 
if  it  does  not  pain  him  ;  in  so  doing,  he  may  use  a  cane  or 
crutches,  according  to  the  weakness  of  the  affected  limb.  Should 
the  patient  need  baths  at  the  same  time,  the  bandage  may  be 
divided  longitudinally,  and  be  removed  before  the  bath  and  re- 
placed subsequently.  This  treatment  has  the  advantage  that  the 
patient  uses  the  muscles  of  the  extremity  somewhat  at  least,  and 
consequently  they  do  not  entirely  atrophy  ;  we  are  not  to  think 
that  stiffness  of  the  joint  must  necessarily  result  from  wearing  the 
plaster-splint  for  a  length  of  time  ;  we  not  unfrequently  find  the 
opposite,  that  is,  that  a  limb  which  Avas  very  slightly  movable  be- 
fore the  application  of  the  dressing  is  more  so  afterward  ;  this  is 
because  the  swelling  of  the  synovial  membrane  often  subsides 
under  the  bandage.  Before  applying  the  plaster-dressing  we  may 
rub  the  limb  with  mercurial  ointment,  or  apply  mercurial  plaster, 
or  even  rub  in  the  nitrate-of -silver  ointment.  In  all  chronic  cases 
of  fungous  inflammation  of  the  joint,  I  cannot  sufficiently  recom- 


CHRONIC   INFLAMMATION   OF  THE   JOINTS.         '  669 

mend  to  you  the  plaster-splint ;  this  treatment  appears  very  inefficient, 
yet  it  is  more  useful  than  all  the  other  remedies  that  we  have  for 
combating  this  disease.  I  can  assure  you  that,  since  following-  this 
treatment  perseveringly,  my  cases  are  less  frequently  complicated 
with  suppuration  and  fistulfe.  Even  when  there  is  evident  fluctuation 
you  may  apply  the  dressing  ;  it  is  true  you  will  rarely  see  the  abscess 
reabsorbed,  still,  when  it  opens  spontaneously  under  the  bandage,  as 
the  patient  will  readily  notice  from  the  moistening  of  the  dressing, 
this  will  take  place  more  quietly,  propitiously,  and  painlessly,  than 
under  any  other  plan  of  treatment.  When  fistulas  have  formed,  we 
may  still  use  the  plaster-splint,  simply  sUtting  it  up  and  putting  in  new 
wadding ;  it  should  be  removed  daily  and  the  sores  dressed,  then  re- 
applied ;  at  the  same  time  the  constitutional  treatment  should  be 
persevered  in.  If  the  limb  be  very  painful,  and  there  are  any  fistu- 
liB  present,  we  should  use  splints  with  openings.  In  this  way  I  have 
occasionally  preserved  a  good,  useful  position  in  joints  moderately 
movable,  w^ere  the  prognosis  was  at  first  very  bad,  and  have  indeed 
been  frequently  most  agreeably  surprised  at  the  results  of  this  treat- 
ment. Extension  must  be  undertaken  very  carefully  in  joints  that 
are  suppurating  or  much  diseased  in  any  way,  and,  if  even  during 
anaesthesia  there  should  be  resistance,  complete  extension  should 
never  be  made  at  one  sitting,  but  it  should  only  be  carried  so  far  as 
may  be  done  without  great  force.  In  knee  and  hijD  diseases  I  use, 
with  great  benefit,  the  extension  by  w^eights  which  has  been  so  often 
recommended,  and  occasionally  thus  prepare  patients,  especially  chil- 
dren, for  the  application  of  the  plaster-bandage.  Yblkmann  deserves 
many  thanks  for  his  energetic  recommendation  of  this  plan  of  treat- 
ment, which  he  calls  the  "  Distractionsmethode."  He  attaches  great 
importance  to  the  fact  that  the  extension  reduces  to  a  minimum  the 
pressure  of  the  articular  surfaces  on  each  other,  that  is  caused  by  the 
tension  of  the  muscles  and  contraction  of  the  ligaments.  The  mode 
of  applying  the  extension  is  so  very  important  for  the  practical  use  of 
this  method,  that  I  must  particularly  recommend  you  to  give  your 
special  attention  to  its  mechanical  application  in  the  clinic. 

Perseverance  on  your  part  and  on  that  of  the  patient  is  absolutely 
necessary,  for  the  cure  of  chronic  inflammations  of  the  joints ;  repre- 
sent to  the  patient,  at  the  outset,  that  this  is  a  disease  of  at  least  sev- 
eral months',  possibly  of  some  years'  duration,  and  that  the  dressing 
is  not  to  be  left  off  till  the  limb  is  free  from  pain,  and  strong  enough 
to  walk  on,  whether  motion  be  lost  or  not.  Regarding  cold  abscesses, 
I  repeat  the  advice  only  to  open  them,  when  you  propose  to  follow 
them  at  some  time  by  an  operation ;  if  this  cannot  be  done,  or  you  do 
not  intend  to  do  it,  leave  the  opening  to  Nature,  even  if  it  should  re- 
quire vears. 


570  TREATMENT. 

So  far,  I  have  briefly  given  you  my  maxims  regarding  the  tieat- 
ment  of  fungous  inflammation  of  the  joint,  but  I  must  not  neglect  to 
call  your  attention  to  the  fact  that  other  surgeons  have  difi"erent  views 
on  the  subject.  There  are  still  advocates  of  the  strong  classical  anti- 
phlogistic treatment,  who,  even  in  chronic  inflammations  of  the  joints, 
from  time  to  time  apply  leeches  or  wet  cups,  put  on  compresses  with 
lead-water,  and  give  cathartics ;  later  they  use  cataplasms,  and  finally 
moxge  and  the  hot  iron.  If  the  disease  continues  to  advance,  if  fis' 
tuljE  have  formed  here  and  there,  if  the  patient  has  become  very 
anaemic,  they  consider  amputation  indicated,  especially  when  there  is 
crepitation  in  the  joint.  This  was  the  old  belief;  the  results  were  gen- 
erally unfavorable  or  favorable,  as  we  may  choose  to  consider  them ; 
that  is,  they  were  the  latter  so  far  as  regards  the  favorable  course  of 
the  amputation,  which  was  made,  sooner  or  later,  under  such  circum- 
stances. Even  now  it  astonishes  me  to  see  how  often  amputations  of 
the  thigh  are  made  for  tumor  albus  of  the  knee,  in  many  hospitals;  it 
is  not  saying  much  to  mention  that,  in  my  own  hospital  service,  I 
have  rarely  found  thigh-amputations  indicated  for  caries  of  the  knee  ; 
but  it  appeared  to  me  very  remarkable  that,  during  the  seven  years 
I  was  assistant  in  the  surgical  clinic  at  the  University  of  Berlin,  there 
were  only  two  amputations  of  the  thigh  for  caries  of  the  knee,  while 
formerly,  in  the  reports  of  the  smallest  hospitals,  several  such  ampu- 
tations were  reported  every  year.  I  am  much  inclined  to  refer  the 
more  favorable  results,  the  rarer  indications  for  amputation,  to  the 
treatment  of  the  disease  by  the  plaster-bandage,  which  was  cliiefly  in- 
troduced and  persistently  carried  out  by  T^?^  Layigenheck  /  and  I  am 
firmly  convinced  that,  by  it,  a  large  number  of  limbs  have  been 
preserved  in  a  relatively  good  condition,  which,  in  former  times,  would 
certainly  have  been  amputated.  I  would  not  recommend  the  abstrac- 
tion of  blood  in  chronic  disease  of  the  joints ;  it  can  only  prove  bene- 
ficial in  subacute  exacerbations,  and  in  these  very  cases  we  have 
better  remedies,  which  are  not  at  the  same  time  injurious ;  for  it  is 
certainl}^  improper  to  abstract  blood  once,  or  even  oftener,  from  pa- 
tients who  are  inclined  to  anaemia  by  their  disease  itself.  In  some 
cases  of  subacute  attacks  in  chronic  inflammation  of  the  joints,  cold 
is  an  excellent  application ;  in  such  cases  I  now  use  ice  with  good  re- 
sults ;  but  I  cannot  say  that  cold  would  be  particularly  beneficial  in 
cases  that  run  their  course  without  outward  sjnnptoms  of  inflamma- 
tion ;  and  it  is  no  slight  affair  to  treat  a  patient  with  ice  for  years, 
keeping  him  in  the  same  position  in  bed  with  a  bladder  of  ice  on  his 
knee,  which,  at  any  rate,  does  not  give  him  much  pain.  Esmarch 
claims  very  favorable  results  for  persevering  treatment  with  ice.  Now 
I  must  speak  of  the  persistent  application  of  heat^  which  mav  be  ac- 


CHRONIC   INFLAMMATION   OF  THE   JOINTS.  571 

complished  by  the  careful  application  of  cataplasms,  compresses  wel 
with  warm  water,  or  even  the  continued  use  of  warm  baths  for  weeks. 
This  treatment  may  be  indicated  when  the  course  of  the  disease  is  ex- 
ceedingly torpid,  when  bad-looking  fistulous  ulcers,  deficient  vascularity 
of  the  granulations,  or  bad,  thin  secretion,  seems  to  indicate  a  moder- 
ate irritation  of  some  kind.  However,  when  high  temperatures  are 
applied,  they  should  not  act  too  long,  or  their  efi'ect  will  be  lost,  and 
there  will  be  complete  relaxation  of  the  parts,  instead  of  the  fluxion 
that  it  was  proposed  to  excite. 

From  the  above  description  of  the  benefits  of  treatment,  you  may 
see  that  in  fungous  inflammations  of  the  joints  the  results  are  gener- 
ally good,  if  we  leave  out  of  consideration  the  greater  or  less  stiff- 
ness of  the  joint  which  remains ;  this  is  particularly  the  case  if  the 
patient  is  treated  early.  Still,  some  cases  are  not  cured,  in  spite  of 
the  most  careful  treatment ;  this  is  partly  due  to  the  anatomical  con- 
dition of  the  joint,  partly  to  the  general  health  of  the  patient.  For 
anatomical  reasons,  disease  of  the  joints  of  the  hands  or  feet  is  the 
most  unfavorable ;  from  the  many  small  bones  and  joints  affected,  the 
progress  is  usually  excessively  tedious  ;  the  disease  may  begin  quite 
clironic  at  one  of  the  small  joints  of  the  hand  or  foot,  may  remain 
stationary  at  this  point  for  a  time,  then  spread  to  the  next  two,  again 
halt  a  while,  or  even  recede  ;  but  a  new  joint  is  attacked ;  suppura- 
tion begins  first  in  one  place,  then  in  another,  the  patient  gTOws 
anaemic  and  weak,  he  is  condemned  to  inaction  for  years,  and  finally 
longs  to  have  the  affected  limb  amputated,  so  that  he  may  once  again 
feel  well,  after  his  years  of  suffering.  In  other  cases  a  scrofulous  or 
tuberculous  cachexia  gradually  induces  anaemia,  indigestion,  fatty  de- 
generation of  the  internal  organs,  tuberculosis  of  the  lungs,  etc.,  so 
that  from  the  general  health  of  the  patient  we  must  give  up  all  hopes 
of  a  cure.  If,  under  such  circumstances,  we  leave  the  disease  to  itself, 
the  patients  die  after  years  of  suffering ;  the  end  comes  the  sooner  the 
larger  the  joint  affected  (knee,  hip),  and  the  greater  the  number  simul- 
taneously affected,  as  is  apt  to  be  the  case  in  scrofula  and  tuberculosis. 
Under  such  circumstances  we  may  resort  to  two  modes  of  treatment : 
1.  Give  up  the  limb  to  save  the  life,  that  is,  amputate  ;  2.  Give  up  the 
attempt  to  cure  the  joint-affection,  cut  out  the  diseased  ends  of  bone, 
so  as  to  save  both  life  and  limb,  that  is,  resect  the  joint. 

Comparing  these  two  remedies  theoretically,  there  can  be  no  doubt 
that  resection  is  preferable  to  amputation,  and  in  principle  this  is  ce]> 
tainl}'  true ;  modern  surgery  is  justly  proud  of  the  institution  of  re- 
section of  joints.  Nevertheless,  certain  circumstances  may  combine 
to  render  amputation  preferable  in  any  given  case  ;  chief  among  these 


572  TREATMEKT. 

IS  the  state  of  the  patient's  general  healtli.  After  resection  of  the 
joint  we  have  left  a  large  wound  with  two  sawed  edges  of  bone, 
which  will  certainly  continue  to  suppurate  for  weeks,  possibly  for 
months  ;  there  may  be  suppuration  of  the  subcutaneous  tissue,  of  the 
sheaths  of  the  tendons,  and  suppurative  periostitis  and  necrosis  of  the 
sawed  edges,  things  which  patients  may  live  through,  but  which  al- 
ways require  time  and  strength.  If,  then,  in  badly-nourished,  cachec- 
tic persons,  loss  of  strength  should  indicate  operative  interference, 
amputation  is  often  a  more  certain  remedy  for  saving  life  than  resec- 
tion. The  surgeon  should  always  think  more  of  saving  the  life  than 
the  limb.  We  have  also  to  answer  the  question,  Can  the  patient 
bear  resection,  with  its  sequelae  ?  It  is  difficult  to  give  a  general  an- 
swer to  this  question ;  even  in  individual  cases  a  decision  may  be  diffi- 
cult :  we  must  determine  whether  the  patient  is  emaciated,  anasmic, 
and  debilitated,  simpl}'^  by  the  drain  on  his  system,  or  if  there  be  more 
serious  lesions  of  internal  organs ;  in  the  latter  case  amputation  would 
be  preferable,  if,  indeed,  any  operation  would  be  serviceable.  Of 
20urse  we  do  not  operate  on  atrophic  children  A^-ith  disease  of  several 
joints,  cold  abscesses,  diarrhoea,  aphtha?,  etc.,  or  on  persons  with 
tuberculous  cavities  in  the  lungs,  or  with  indurated,  fatty  liver  and 
spleen,  or  on  old  marasmic  individuals  ;  we  cannot  give  any  aid  to 
such  patients.  But  a  still  more  important  question  is.  Which  opera- 
tion is  less  dangerous  to  life  ?  We  cannot  give  a  general  answer  to 
this  question ;  we  must  separately  consider  the  joints  concerning 
which  tlie  question  of  resection  arises.  In  caries  of  the  shoulder-]omi 
resection  is  less  dangerous  than  disarticulation  of  the  arm  at  the 
shoulder-joint ;  the  same  is  true  of  the  ?dp-joint  /  hip-joint  amputa- 
tions are  among  the  most  dangerous  in  surgery,  while  in  young  sub- 
jects resection  is  not  so  very  fatal.  Hence  we  are  not  to  tliink  of 
exarticulation  at  the  shoulder  or  hip  on  account  of  caries ;  here  the 
only  question  is.  Is  the  general  health  of  the  patient  such  that  we 
should  let  the  disease  run  its  course,  or  shall  we  arrest  it  by  resection  ? 
In  the  most  favorable  cases  of  spontaneous  cure  there  will  be  anch}'- 
losis  in  a  bad  position ;  if  recovery  takes  place  after  resection,  the 
extremity  remains  movable  at  the  shoulder  or  hip  joint.  These  chances 
speak  strongly  for  resection,  especially  at  the  shoulder-joint ;  here  we 
might  decide  on  resection  quite  early,  even  in  order  to  get  the  patient 
about  soon  and  in  good  order.  Resection  of  the  hip  is  open  to  one 
grave  objection :  we  cannot  resect  the  acetabulum,  which  is  usually 
diseased  at  the  same  time,  or  we  can  only  do  so  imperfectly ;  hence, 
when  the  joint  is  much  diseased,  the  resection  is  imperfect ;  slighter 
grades  of  the  aiFection  may  even  recover  without  operation. 

In  the  elbow-joint  the  state  of  affiiirs  is  more  favorable,  perhaps  the 


CHRONIC   INFLAMMATION    OF   THE   JOINTS.  573 

most  favorable ;  the  resection  of  this  joint  is  not  more  dangerous  than 
amputation  of  the  arm  ;  but,  in  favorable  cases,  after  resection,  quite 
a  useful  joint  is  left,  while  after  spontaneous  recovery  there  is  gen- 
erally anchylosis ;  in  these  cases  the  choice  is  easier :  we  prefer  re- 
section of  the  elbow-joint,  not  because  the  operation  must  be  done  to 
save  life,  for  caries  of  this  joint  is  only  dangerous  from  long  duration, 
but  because,  while  the  danger  is  relatively  slight,  it  oiFers  good  chances 
of  motion,  and  in  any  other  case  there  is  usually  anchylosis ;  indeed, 
the  anchylosed  joint  has  even  been  sawed  out  in  order  to  obtain  a 
movable  false  joint.     Unfortunately,  more  recent  observations  on  the 
motiUty  of  arms  with  resected  joints  have  shown  that  the  false  joints 
formed  after  operation  become  more  relaxed  in  the  course  of  years,  so 
that  finally  the  operated  extremity  does  not  remain  as  useful  as  was 
formerly  supposed.     The  case  is  very  different  with  the  Tcnee-joint ; 
here  resection  is  quite  a  dangerous  operation,  being  on  a  par  with 
high  amputations  of  the  thigh ;  after  resection  of  tlie  knee  we  only 
obtain  anchylosis,  which  is  also  the  result  of  spontaneous  recovery. 
Now,  as  this  operation  is  quite  dangerous,  and  as  it  gives  no  better 
results  than  non-operative  treatment,  in  case  the  disease  is  arrested,  it 
should  only  be  done  to  save  life,  and,  even  in  this  respect,  it  is  of 
doubtful  advantage.     I  have  rarely  decided  on  an  operation  for .  caries 
of  the  knee-joint,  either  for  amputation  or  resection  ;  w^e  can  only  pro- 
pose amputation  when  all  treatment  is  fruitless,  and  the  patient  is 
failing  rapidly,  or  when  it  is  an  old  person  in  whom  extensive  caries 
of  the  joint  would  be  very  unlikely  to  heal. 

The  above  are  my  personal  opinions,  which  constantly  become 
more  fixed,  as  I  see  more  such  knee-diseases  recover  spontaneously. 
I  have  seen  many  children  die  of  coxitis,  and  consequently  am  rather 
in  favor  of  resection  of  the  hip,  in  spite  of  the  want  of  success  of  my 
own  operations  ;  the  only  deaths  I  have  seen  from  caries  of  the  knee 
have  been  in  old,  marasmic  persons  and  those  with  tubercles  and  ex- 
tensive cavities  in  the  lungs,  while  they  have  been  rare  in  children ; 
in  all  of  these  cases  operation  would  have  been  useless.  H§re  you 
have  my  belief  about  operations  of  caries  of  the  knee.  Other  surgeons 
have  different  opinions ;  in  England,  especially,  the  operation  is  so 
popular  that  it  is  very  often  performed.  I  believe  that  many  German 
surgeons  share  my  views  on  this  subject,  others  are  more  undecided, 
as  they  view  this  operation  more  favorably  from  having  seen  a  few 
successful  resections  of  the  knee-joint.  Formerly,  I  was  entirely  op 
posed  to  resection  of  the  knee-joint,  but  have  been  rather  unsettled 
by  a  series  of  favorable  results  that  I  have  lately  had  from  this  oper- 
ation. If  the  cases  with  good  chances  be  chosen  for  operation,  and 
unfavorable  or  doubtful  ones  never  operated  on,  the  operations  will  be 


674  TREATMENT. 

mostly  successful,  but  few  patients  will  be  cured.  The  same  is  true 
of  most  great  operations  ;  if  one  has  some  experience,  and  does  not 
hesitate  to  send  most  cases  away  uncured,  interesting  himself  only 
in  the  favorable  cases,  he  may  soon  attain  the  reputation  of  a  very 
fortunate  operator.  Many  eminent  surgeons  deceive  themselves  in 
this  way. 

Now  we  come  to  the  wrist-joint ,'  here  resection  usually  consists  in 
the  removal  of  all  the  bones,  and  sawing  off  the  lower  surfaces  of  the 
radius,  perhaps  also  those  of  the  ossa  metacarpi.     I  have  performed 
this  operation  several  times,  occasionally  with  brilliant  results,  the  hand 
becoming  perfectly  movable  and  the  fingers  useful ;  two  of  the  pa- 
tients were  seamstresses,  and  were  able  to  resume  their  occupation, 
the  third  and  fourth  unfortunately  lost  patience  ;  after  the  operation, 
when  the  wound  had  closed  except  two  fistulas,  and  the  pain  had 
ceased,  they  stopped  treatment ;  there  were  still  some  carious  spots 
in  the  metacarpal  bones  which  should  have  been  extirpated,  when  the 
result  would  certainly  have  been  as  good  as  it  was  in  the  previous 
cases.     I  should  have  liked  to  resect  the  hand  more  frequently,  but 
several  times  have  submitted  to  the  patient's  special  request  to  am- 
putate the  forearm.     It  must  seem  strange  that  a  patient  does  not 
readilj'^  consent,  when  the  surgeon  proposes,  by  a  tolerably  safe  opera- 
tion, such  as  resection  of  the  wrist,  to  preserve  the  hand ;  I  always 
felt  obliged  to  say  that  it  would  be  several  months  before  the  wound 
healed,  so  that  the  patients  should  not  expect  too  much ;  they  replied 
that  it  was  too  long  a  time,  they  had  not  used  the  hand  for  four,  five, 
and  eight  years,  and  it  always  pained  them  ;  they  were  tired  of  treat- 
ment, and  had  decided  to  lose  the  hand,  so  they  would  not  again  un- 
dertake a  long  course  of  treatment.     I  have  told  j^ou  this  that  you 
may  see  M'hat  obstacles  the  surgeon  runs   against  when  he  honestly 
tries  to  do  the  best.     All  the  cases  of  caries  of  the  wrist  are  by  no 
means  suited  for  resection ;  we  never  decide  on  an  operation  before 
there  is  extensive  destruction  of  the  bones,  although  we  know  that 
caries  of-  the  wrist  very  rarely  spontaneously  recovers   with   movable 
joint.     Caries  of  the  Avrist  is  not  fi'equent  as  compared  with  that  of 
the  knee  and  hip,  and  is  particularly  rare  in  children,  being  more  fre- 
quent in  adults.     The  cause  of  the  difficulty  of  recovery  is  partly  due 
to  local  conditions  Avhich  we  have  previously  described.    Besides  this, 
there  are  about  the  hand  so  many  tendons,  most  of  whose  sheaths  par- 
ticipate in  the  disease  ;  the  fingers  are  stifily  extended,  the  metacarpal 
Dones,  radius,  and  ulna,  are  also  frequently  diseased,  though  they  may 
be  only  affected   with  periostitis.     The  other  soft  parts   about  the 
hand,  especiaJly  the  skin,  are  perforated  by  numerous  fistulae,  or  even 
extensively  destroyed,  so  that  the  most  favorable  circumstances  for 


CHRONIC   INFLAMMATION   OF   THE   JOINTS.  575 

resection  do  not  exist.  Hence,  where  extensive  caries  of  the  hand  is 
accompanied  by  considerable  degeneration  of  the  neighboring  parts, 
amputation  of  the  forearm  will  justly  assume  its  old  position.  Ex- 
traction of  single  metacarpal  bones,  or  simply  sawing  off  the  radius,  is 
rarely  sufficient;  I  have,  indeed,  seen  cases  where  the  disease  was 
limited  to  one  or  two  metacarpal  bones;  these  had  become  necrosed, 
and  the  disease  terminated  at  that  pomt ;  one  patient  was  sent  to  me 
for  amputation  of  the  hand,  and  was  much  pleased  when,  after  exam- 
ination, I  told  him  that  amputation  was  not  necessary.  But  these 
cases  are  rare ;  usually  the  disease  advances,  and  is  not  an-ested  by 
the  extirpation  of  the  bones  which  are  chiefly  diseased.  I  think  that, 
on  the  whole,  total  resection  of  the  wrist  is  still  too  little  employed ;  ac- 
cording to  my  experience,  it  is  worthy  of  the  greatest  attention  from 
surgeons.  This  operation,  as  well  as  a  similar  one  on  the  foot,  of  which 
we  shall  speak  shortly,  is  well  supported  by  a  reasoning  that  has  been 
falsely  applied  to  resections  in  general;  i.  e.,  if  resection  does  not 
arrest  tlie  local  disease,  we  may  still  amputate.  In  resections  of  the 
hand  and  foot  this  is  true,  and  they  are  rarely  followed  by  pysemia, 
but  the  case  is  not  the  same  with  the  shoulder,  hip,  elbow,  and  knee. 
If  these  operations  are  unsuccessful,  if  suppuration  be  exhausting,  or 
pyiiemia  occur,  we  can  hope  little  from  amputation  or  exarticulation. 
Lastly,  Ave  come  to  the  ankle-joint,  comprising  the  joints  of  the  tarsus 
as  well  as  the  tibio-tarsal  articulation.  The  circumstances  here  very 
closely  resemble  those  for  the  wrist ;  although  caries  of  single  bones, 
as  the  not  mifrequent  caries  necrotica  of  the  calcaneus,  will  spontane- 
ously recover  with  time,  especially  in  children,  just  as  scrofulous  caries 
of  the  fingers,  toes,  metatarsal  and  metacarpal  bones  do,  even  in  young 
adults,  caries  of  the  joints  of  the  foot  rarely  recover  spontaneously, 
and  in  old  persons  hardly  ever  do  so.  Consequently,  in  these  cases 
operation  will  frequently  be  indicated  at  some  stage  of  the  disease, 
and  on  superficial  observation  we  might  think  that  resection  and  ex- 
tirpation of  bone  should  be  very  commonly  resorted  to ;  but,  practi- 
cally, there  are  two  objections  to  the  extensive  resort  to  these 
operations  in  caries  of  the  foot :  1.  The  experience  that,  after  extirpa- 
tion of  one  bone,  the  disease  often  attacks  another,  and  consequently 
perfect  recovery  does  not  result.  2.  The  fact  that  the  foot  must 
always  retain  sufficient  firmness  for  the  patient  to  walk ;  so,  while  we 
may  remove  the  cuneiform  bones,  the  scaphoid  and  cuboid,  or  even 
the  astragalus  or  calcaneus,  if  we  remove  both  the  latter  bones,  and 
perhaps  also  saw  off  the  articulating  surfaces  of  the  tibia,  we  should 
have  a  rather  useless  foot,  which  would  be  worse  than  a  good  stump. 
The  cicatrices  occurring  at  the  place  Avhence  the  bone  was  extirpated 
contract  greatly  after  a  time,  and  even  if  some  bone  form  in  this  cica- 


576  TREATMENT. 

trix,  still  it  is  not  regenerated  as  after  necrosis,  but  the  foot  contracts 
greatly  at  the  point  from  wliicli  the  bone  is  absent,  and  thus  becomes 
distorted  and  useless.  These  are  decided  objections;  moreover,  a 
good  stump,  such  as  is  left  by  Choparfs  or  Plrogoff''s  operation,  is 
often  just  as  good  or  even  better  for  walking  than  a  weak,  deformed 
foot,  and  it  requires  several  months  to  get  the  latter  into  shape, 
while  the  former  may  be  obtained  in  six  to  eight  weeks.  In  one  case, 
I  removed  all  three  cuneiform  bones,  and  the  os  cuboid,  Avith  good 
results ;  in  other  cases,  in  boj^s,  I  have  removed  the  astragalus  ;  then 
the  tibia  articulated  with  the  calcaneus,  the  new  joint  remained  mova- 
ble, and  the  patient  did  not  even  limp  ;  such  results  are  very  encour- 
aging for  this  operation.  Another  time  I  wished  to  remove  the  cal- 
caneous  alone  for  caries,  but  unexpectedly  found  the  lower  part  of  the 
astragalus  affected,  and  had  to  remove  it  also ;  the  result  was  miser- 
able :  the  young  boy  lay  six  months  in  the  ward,  and  even  then  did 
not  recover,  so  I  amputated  at  the  lower  part  of  the  leg,  and  the 
wound  healed  by  first  intention  ;  a  few  weeks  later,  the  patient  left 
the  hospital  well,  with  a  good  wooden  leg,  glad  to  be  rid  of  his  sore 
foot.  The  very  favorable  results  of  Pirogoff''s  amputation  make  a 
strong  opposition  to  resection  of  the  ankle-joint,  and  I  think  that 
experience  will  soon  speak  more  strongly  than  now  against  too  great 
employment  of  exsection,  and  for  amputations  through  the  foot. 

Resections  of  joints,  which  have  excited  so  much  controvers}'  the 
last  twenty  years,  at  first  appeared  so  brilliant  from  the  favorable 
results  in  certain  joints,  such  as  the  elbow  and  shoulder,  that  they 
were  sometimes  too  much  resorted  to  ;  this  is  the  fate  of  all  inventions 
of  the  human  mind.  We  are  only  now  gradually  coming  to  certain 
indications  for  these  operations ;  of  course  statistics  had  first  to  be 
collected,  and  it  was  soon  found  that  resection  was  of  varied  value  in 
different  joints.  Although  I  am  not  prepared  to  say  that  the  question 
is  even  now  settled,  still  I  believe  I  have  given  you  a  correct  resume 
of  the  present  position  of  affairs. 

I  cannot  refrain  from  making  one  observation  at  the  close  of  this 
chapter.  In  the  Canton  Zurich  patients  who  had  been  successfully 
treated  for  caries,  by  resection  or  amputation,  often  returned,  and, 
sad  to  say,  many  of  them  who,  after  suffering  for  years,  had  been  per- 
fectly cured,  and  had  left  the  hospital  quite  strong,  came  back  after  a 
year  or  two  with  caries  of  other  bones,  or  with  tubercles  of  the  lungs, 
and  often  died  there.  I  have  been  unable  to  gather  any  extensive 
statistics  as  to  the  final  terminations  of  bone  and  joint  diseases,  but 
fear  that  they  will  prove  much  more  unfavorable  than  we  generally 
incline  to  believe. 


CHROXIC   INFLAMMATION   OF  THE   JOINTS.  5V7 

[Instead  of  simple  compression,  you  may  render  tbe  extremity 
entirely  bloodless  by  means  of  JEsmarcK's  bandage  ;  at  first  this 
anifimia  may  be  kept  up  five  minutes,  and  subsequently  for  a  quarter 
or  half  an  hour.  Regularly  repeated  daily,  in  the  early  stages  of 
tumor  albus,  this  treatment  has  given  me  very  good  results. 

When  cold  abscesses  have  developed,  under  the  present  per- 
fected system  of  antisepsis,  you  may  open  them,  if  you  are  sure  of 
being  able  to  reach  the  whole  extent  of  the  abscess-cavity.  You 
divide  the  soft  parts,  let  out  the  pus,  and,  with  the  sharp  scoop, 
scrape  the  inner  surface  of  the  cavity,  fill  it  with  iodoform,  unite 
the  wound,  except  at  the  points  for  drainage,  and  apply  Lister's 
dressing.  Tbe  limb  should  be  kept  immovable.  Should  you  await 
the  spontaneous  opening  of  the  abscess,  it  probably  will  do  no 
harm. 

It  remains  to  be  seen  whether  the  statistics  of  knee-joint  resec- 
tions will  be  decidedly  changed  by  the  employment  of  iodoform  ; 
experience  thus  far  is  encouraging. 

Let  me  call  your  attention  to  the  etiological  relation  of  chronic 
bone  and  joint  affections,  and  acute  infectious  diseases  of  children, 
such  as  the  acute  exanthemata,  diphtheria,  pertussis,  etc.] 

Less  attempt  is  made  than  formerly  to  obtain  movable  false 
joints  after  resection  ;  but  more  frequently  we  seek  by  partial  re- 
moval of  the  bones  chiefly  diseased,  under  Lister's  method,  and  with 
the  least  possible  suppuration,  to  cause  anchylosis  of  the  joint. 

Unfortunately,  return  of  the  disease  is  not  rare,  even  in  joints 
which  had  been  healed  by  anchylosis  for  years.  Persons  who  have 
suffered  from  the  above  forms  of  chronic  articular  inflammation 
rarely  attain  old  age.  You  Avill  find  few  persons  above  forty  or  fifty 
years  old  with  anchylosis  from  tumor  albus.  This  seems  another 
proof  that  these  diseases  are  associated  with  some  constitutional 
taint,  difiicult  as  it  is  in  all  cases  to  prove  this,  and  to  demonstrate 
it  to  those  who  are  inclined  to  explain  all  diatheses  and  dyscrasice 
as  vague  theories  of  old  physicians. 
38 


578  CHRONIC  IXFLAMMATIOX  OF  T.1E    JOINTS. 


LECTURE    XXXIX. 

5_ Chronic  Serous  Synovitis. — Hydrops  Articulorum  Clironicus:  Anatomy,  Symp- 
toms Treatment. — Typical  Recurrent  Dropsy  of  the  Knee-Joint. — Appendix: 
Chronic  Dropsies  of  the  Sheaths  of  the  Tendons,  Synovial  Hernias  of  the  Joints 
and  Subcutaneous  Mucous  Bursae. 

5.— CHKONIC  SEROUS  SYNOVITIS.— HYDROPS   ARTICULORUM    CHRONI- 
CCS.— HYDRARTHRUS. 

The  chronic  diseases  of  the  joints  that  we  have  now  to  describe 
are  much  more  rare  than  fungous  synovitis  and  its  results,  which  we 
have  already  described;  taken  altogether,  they  are  scarcely  so  fre- 
quent as  the  former,  and,  as  a  body,  they  form  a  decided  contrast  to 
suppurating  inflammations  of  the  joints,  for  they  never  spontaneously 
suppurate,  they  only  do  so  when  acted  on  by  repeated  irritations,  in- 
juries, etc.  We  shall  commence  with  the  most  simple  of  these  forms, 
with  chronic  serous  synovitis,  or  hydrops  articulorum  clironicus,  or 
hydrarthrus.  The  disease  consists  in  a  morbid,  slowly-increasing 
collection  of  rather  thin  sjmovia;  the  synovial  membrane  changes 
very  little,  it  gradually  becomes  somewhat  thicker  and  firmer,  the 
connective  tissue  increases,  but  without  any  marked  increase  of  vas- 
cularity ;  the  tufts  elongate,  and,  although  the  vessels  form  into  loops 
at  their  apices,  the  substance  retains  the  firmness  of  connective  tissue, 
while  from  plastic  and  serous  infiltration  it  grows  soft  and  resembles 
granulations  in  fungous  synovitis.  In  serous  synovitis  this  does  not 
occur ;  the  entire  pathological  changes  of  tissue  are  very  slight,  even 
when  the  disease  has  lasted  a  long  while.  Some  surgeons  wish  to 
consider  these  dropsies  of  the  joints,  as  well  as  similar  diseases  of  the 
mucous  bursoe,  as  not  belonging  to  the  chronic  inflammations,  but  as 
constituting  peculiar  diseases.  This  does  not  seem  to  me  justifiable. 
No  one  will  dispute  that  chi-onic  catarrhs  of  the  mucous  membranes, 
with  a  tendency  to  hypersecretion,  are  to  be  classed  among  the  chronic 
inflammations ;  chronic  dropsy  of  the  synovial  membrane  is  perfectly 
analogous  to  chronic  catarrh  of  the  mucous  membranes. 

Chronic  dropsy  of  the  joints  is  often  the  remains  of  an  acute  artic- 
ular dropsy,  caused  by  contusions,  catching  cold,  etc.,  as  has  already 
been  described ;  but  in  many  cases,  also,  the  disease  is  chronic  from 
the  start,  and  remains  so.  Hydrarthrus  is  most  common  in  young 
men,  and  occurs  most  frequently  in  the  knee-joint ;  it  often  comes  on 
both  sides ;  it  is  very  rare  in  the  shoulder,  hip,  or  elbow ;  I  have  never 
seen  a  pure  case  of  it  in  the  other  joints.  When  the  disease  is  well 
advanced  it  is  readily  recognized,  and  even  the  laity  know  it  as 
"  dropsy  of  the  joint."     The  joint   is  much   swollen,  fluctuates  all 


I 


CHRONIC  SEROUS  SYNOVITIS.  5Y9 

over ;  in  the  knee  we  have  also  the  motion  of  the  patella ;  it  is  lifted 
up  by  the  fluid,  and  may  be  readily  pressed  again  into  the  intercon- 
dyloid  fossa,  occasionally  with  a  perceptible  sound.  As  the  surfaces 
of  the  joint  are  united  by  firm  ligaments  (in  the  knee  by  the  lateral 
and  crucial  ligaments),  which  are  not  so  easily  stretched,  the  fluid 
collects  chiefly  in  the  mucous  bursas  adjacent  to  the  joint,  and  on  this 
account  we  may  often  diagnose  the  swelling  as  synovitis  by  simple 
inspection,  especially  in  the  knee-joint,  where  the  bursas  under  the 
tendons  of  the  extensors  at  both  sides  of  the  patella,  and  in  the 
pophteal  space,  are  greatly  distended  by  the  fluid;  while,  on  the 
other  hand,  in  regular  swelling  of  the  capsule,  the  enlargement  is 
regularly  round.  Sometimes,  also,  patients  with  this  disease  can 
move  their  joints  quite  freely  and  Mathout  pain ;  they  can  often  walk 
quite  a  distance,  and  occasionally  have  so  little  inconvenience  that 
they  do  not  ask  advice  of  the  physician ;  even  examination  of  the 
joint  by  palpation  is  painless.  Where  the  dropsy  of  the  joint  is 
considerable,  great  exertion  readily  causes  fatigue  of  the  limb,  as  well 
as  pain  and  increased  exudation ;  however,  after  resting  a  while,  this 
passes  ofi^,  and  generally  the  inconvenience  is  very  shght. 

The  prognosis  is  good  in  so  far  as  these  di'opsies  of  the  joint  lead 
to  nothing  further;  the  fluid  may  increase  enormously,  but  that  is  all ; 
unless  there  be  some  overstraining  or  injury,  the  disease  remains  the 
same.  As  regards  recovery,  the  prognosis  is  most  favorable  in  those 
cases  where  the  disease  remains  after  an  acute  or  subacute  commence- 
ment; in  these  cases,  as  a  rule,  complete  recovery  takes  place  by 
reabsorption,  although  it  may  be  slow.  On  the  other  hand,  those 
cases  where  the  disease  is  chronic  in  its  commencement  and  course 
are  very  obstinate,  and  are  often  extremely  difficult  to  cure. 

Tlae  treatment  consists  in  the  application  of  the  remedies  already 
described,  which  are  to  be  perseveringly  used  while  the  joint  is  kept 
at  perfect  rest,  viz.,  tincture  of  iodine,  flying  blisters,  and  compres- 
sion. The  latter  is  the  most  effective  remedy,  but  it  must  be  strong 
and  continued  (forced  compression,  according  to  Volkmann) ;  we  may 
apply  firm  dressings  with  moist  or  elastic  bandages ;  the  patient  must 
lie  still  during  the  treatment ;  if  there  should  be  any  oedema  of  the 
leg,  it  will  do  no  harm,  but,  if  the  toes  grow  blue  and  cold,  the  band- 
age must  be  removed.  If  the  patients  will  not  submit  to  this  treat- 
ment, we  may  let  them  wear  a  large  mercurial  plaster,  with  a  snugly- 
fitting  knee-cap  of  leather  with  elastic  insertions,  which  prevents  too 
much  motion  of  the  joint,  and  gives  the  limb  more  firmness  and  se- 
cmity  in  walking.  If  all  this  treatment  does  no  good  after  months 
or  years,  or  if  the  improvement  has  only  been  temporary,  we  may  still 
resort  to  simple  tapping,  or  to  tapping,  followed  by  injection  of  iodine. 


580  CHRONIC  INFLAMMATION   OF   THE   JOINTS. 

Usually  simple  tapping  does  little  good.  You  pass  a  fine  trocar  into 
the  joint  alongside  of  the  patella,  allow  the  fluid  to  flow  out  slowly, 
and  close  the  canula  a  Httle  before  it  has  all  escaped,  so  that  no  air 
may  enter  the  joint,  then  cover  the  wound  with  adhesive  plaster; 
now  paint  the  joint  with  tincture  of  iodine  and  envelop  it  with  wet 
bandages  or  a  coUodial  bandage,  and  in  some  cases  you  may  attain  a 
cure ;  there  will  be  a  rapid  collection  of  serum  and  some  pain  in  the 
joint ;  this  new  fluid  may  be  completely  absorbed.  If  this  operation 
has  done  no  good,  if  the  fluid  collects  again  to  the  same  amount,  and 
remains  unchanged,  you  may  make  the  tapping  followed  by  injection 
of  iodine.  This  operation  is  not  free  from  danger ;  you  perform  it  as 
follows :  First  tap  the  joint  carefully,  as  above  directed,  then  fill  a 
well-made  syringe  with  a  mixture  of  officinal  tincture  of  iodine  and 
distilled  water  in  equal  parts,  or,  if  you  wish  to  be  very  careful,  one 
part  of  tincture  of  iodine  to  two  of  water ;  after  seeing  that  there  is 
no  air  left  in  the  syringe,  you  may  inject  from  one  to  two  ounces  of 
this  mixture,  according  to  the  amount  of  previous  distention  of  the 
joint ;  keep  the  fluid  in  the  joint  three  to  five  minutes,  according  to 
the  pain  induced,  then  let  it  escape  slowly ;  now  carefully  close  the 
wound,  and  make  compression,  as  above  described.  A  new  acute 
serous  exudation  always  results  ;  this  remains  stationary  about  eight 
days,  and  is  then  slowly  absorbed,  and  recovery  usually  follows.  Of 
course,  under  such  treatment,  as  after  simple  tapping,  the  patient 
must  remain  absolutely  quiet,  for  there  is  always  inflammation,  and 
perfect  rest  is  the  first  requirement  in  inflamed  joints.  It  is  not  quite 
evident  why  it  hajDpens  that,  when  tincture  of  iodine  comes  in  contact 
with  a  serous  membrane  which  was  disposed  to  excessive  secretion, 
even  for  a  short  time,  it  should  have  such  an  influence  in  altering  and 
arresting  the  secretion  ;  formerly  it  was  thought  that  after  these  in- 
jections, which  were  advantageously  used  in  many  chronic  dropsies 
of  serous  membranes,  there  was  adhesive  inflammation,  a  union  of 
the  surfaces  of  the  serous  sac,  and  its  consequent  obliteration ;  this  is 
b}'  no  means  the  case,  at  least  after  the  successful  injections  of  iodine 
in  hydrops  articuli ;  if  such  adhesions  occurred  here,  the  joint  would 
become  stiff.  What  really  occurs  is  as  follows :  The  iodine  is  de- 
posited in  the  surface  of  the  membrane  and  in  the  endothelium ;  it 
remains  here  for  months,  at  least,  and  by  its  presence  appears  to  pre- 
vent further  secretion.  At  first  there  is  strong  flvixion  with  serous 
exudation  (acute  serous  synovitis),  but  the  serum  is  again  absorbed 
by  the  still-distended  vessels,  and  subsequently  the  membrane  shrinks 
to  the  normal  volume  by  condensation  of  the  connective  tissue,  Avhich 
subsequently  remains  more  dense.  So  we  may  consider  the  process 
of  cui-e   as  analogous  to  the  similar  process  in  the  tunica  vaginalis 


CHRONIC  SEROUS  SYNOVITIS.  681 

propria  testis,  in  the  cure  of  hydrocele  of  the  tunica  vaginalis,  or 
water-rupture ;  after  injections  of  iodine  in  hydrocele,  there  has  been 
an  opportunity  of  making  many  examinations,  from  which  the  course 
of  the  cure  appears  to  be  as  above  stated ;  the  shrinkage  of  the  serous 
membrane,  with  new  formation  of  endothelium,  seems  to  me  to  be  the 
final  cause  of  the  arrest  of  the  secretion. 

Iodine  injections  in  hydrarthrus  are  made  by  few  surgeons ;  I  have 
seen  them  made  three  times,  and  have  made  two,  always  with  good 
result ;  but  this  is  not  always  the  case ;  then  they  must  be  repeated, 
but  I  warn  you  against  repeating  them  too  soon :  you  should  at  all 
events  first  allow  the  acute  stage  after  the  operation  to  subside. 
Cases  have  also  occurred  where  severe  inflammations  of  the  joint  have 
resulted  after  these  iodine  injections,  which  have  been  most  used  in 
France  because  they  are  a  French  invention  (of  JBoinet  and  Velpeaii) ; 
as  so  often  happens  in  traumatic  articiilar  inflammations,  the  acute 
serous  synovitis  became  purulent;  in  favorable  cases  there  was  re- 
covery with  anchylosis,  in  some  cases  amputation  was  necessary,  in 
other  cases  the  patients  died  of  pyaemia.  These  unfortunate  termina- 
tions of  an  operation  done  for  a  disease,  which  is  obstinate  it  is  true, 
but  not  dangerous  to  life,  have  justly  rendered  injection  of  iodine  into 
the  joints  unpopular ;  it  is  always  dangerous  to  the  joint  and  to  life, 
and  hence  should  be  done  as  rarely  as  possible. 

The  diagnosis  of  hydrarthrus  is  usually  simple,  and  the  disease 
always  very  difi'erent  from  chronic  fungous  purulent  synovitis  ;  how- 
ever, I  would  caution  you  that,  in  the  commencement  of  tumor  albus, 
also,  there  is  occasionally  a  slight  amount  of  serous  exudation,  and 
even  fluctuation,  in  the  joint,  so  that  at  first  the  diagnosis  cannot  always 
be  exactly  made ;  but  observation  for  a  few  weeks  suffices  to  show  the 
nature  of  the  disease,  and,  moreover,  hydrops  articulorum  occurs  chiefly 
in  young  adults,  while  tumor  albus  is  most  frequent  in  children. 


APPENDIX. 


CHEONIC   DROPSIES    OF    THE  SHEATHS  OP   THE    TEIODONS,    MUCOUS    BURSA 
AND  SYNOVIAL  HERNIAS. 

We  shall  now  say  something  of  the  chronic  dropsies  of  the  sheaths 
of  the  tendons.  The  disease  consists  in  an  abnormal  increase  of  the 
synovia,  secreted  from  the  sheath  of  the  tendon,  for  facihtating  the 
motion  of  the  tendon,  and  in  abnormal  distention  of  the  sac.  The 
sheaths  of  the  tendons  of  the  hand  are  most  frequently  affected. 
There  is  a  gradual  formation  of  a  swelling  in  the  hollow  of  the  hand 
and  lower  end  of  the  volar  side  of  the  forearm  ;  and  we  may  distinctly 
feel  the  passage  of  a  fluid  in  the  sheath  of  a  tendon  from  the  vola 


682  TREATMENT   OF  GANGLION. 

manus  to  the  forearm,  under  tlie  ligamentum  carpi  volare  and  back 
again.  The  fingers  are  generally  flexed  and  cannot  be  fully  extended ; 
the  movements  of  the  hand  and  fingers  are  somewhat  limited ;  there 
is  not  necessarily  any  pain,  and  the  patients  do  not  usually  apply  to 
a  surgeon  till  the  disease  has  attained  a  high  grade. 

Another  form  of  this  disease  is  partial  hernial  ectasia  of  the  sheath 
of  the  tendon,  with  dropsy.  On  the  sheath  there  forms  a  sac-like  pro- 
trusion, about  the  size  of  a  pigeon's  egg,  containing  an  abnormal 
amount  of  synovia  of  the  sheath. 

Fig.  9". 


D'u»?ram  of  the  ordinary  ganglion,    n,  tendon ;  6.  eheath  of  tiie  tendon  with  dropsical  Lernia! 
protraeion  upward;  c,  akin. 

In  ordinary  surgical  language  this  is  called  a  ganglion  when  it 
comes  on  the  back  of  the  hand.  It  is  of  far  more  frequent  occurrence 
than  dropsy  of  the  whole  sheath  of  the  tendon,  but  it  only  comes  at 
certain  places.  Ganglia  are  most  common  on  the  dorsal  surface  of  the 
wrist,  where  they  arise  from  the  sheaths  of  the  extensor  tendons ;  they 
are  more  rare  on  the  volar  surface  of  the  hand  and  higher  up  the  fore- 
arm, rarer  still  on  the  foot,  where  I  have  found  them  most  frequently 
on  the  sheaths  of  the  peroneal  tendons.  These  ganglia  usually  con- 
tain a  thick,  mucous,  vitreous-looking  jelly.  The  contents  of  previous- 
ly-described extensive  exudations  in  the  sheaths  of  the  tendons  may 
also  consist  of  clear  jelly ;  but  frequently  there  are  also  innumerable 
white  bodies,  Hke  melon-seeds,  which  are  not  organized,  but  usually 
consist  of  pure  amorjDhous  fibrine.  These  bodies  may  be  present  in 
such  numbers  that  no  fluid  can  be  evacuated  on  puncturing  the 
sacs.  Sometimes  we  can  diagnose  these  fibrine-kernels  beforehand, 
from  their  giving  rise  to  a  strong  friction-sound,  such  as  occurs  in 
subacute  inflammation  of  the  sheath  of  the  tendons. 

In  the  treatment,  we  must,  above  all,  bear  in  mind  that  we  should 
avoid  any  operation  that  might  induce  suppurative  inflammation  of 
the  sheath  of  the  tendon,  and  might  disable  for  a  long  time  or  jDOssibly 
cause  a  stiff  hand  in  a  patient  who  had  been  but  little  inconvenienced 
by  his  ganglion.  Remedies,  such  as  mercury  and  iodine,  which  so 
stimulate  reabsorption  in  cases  of  acute  or  subacute  inflammation,  are 
of  little  use  here.  The  simplest  and  the  most  frequent  operation  is 
rupture  of  the  ganglion.     If,  as  is  customary,  the  ganglion  be  on  the 


TREATMENT  OF   GANGLION.  533 

doreal  surface  of  the  hand,  we  take  the  flexed  hand  of  the  patient  bo- 
fore  us,  place  the  two  thumbs  close  together  on  the  ganglion,  and 
make  strong  pressure  ;  this  sometimes  ruptures  the  sac,  the  fluid  is 
effused  into  the  subcutaneous  tissue,  and  then  readily  reabsorbed. 
"When  this  method  succeeds  readily,  there  is  not  much  objection  to 
it,  except  that  it  does  not  always  cause  a  radical  cure.  The  small 
subcutaneous  opening  of  the  sac  soon  closes,  the  fluid  collects  again, 
and  the  disease  continues  as  before.  If  we  cannot  rupture  the  sao 
with  the  thumbs,  it  has  been  recommended  to  do  so  with  a  quick  blow 
by  a  broad  hammer ;  although  this  succeeds  now  and  then,  I  would 
not  recommend  it  to  you,  for  if  unskilfully  done  it  may  cause  a  severe 
contusion,  whose  consequences  we  cannot  always  master.  When  the 
sac  is  too  thick  to  rupture  with  the  finger,  I  employ  subcutaneous  dis- 
cision  /  I  pass  a  narrow,  short,  curve-pointed  knife  {DieffenhacK s 
tenotome)  horizontally  into  the  sac,  and  with  the  point  of  the  knife 
make  numerous  incisions  on  the  inner  wall  of  the  sac,  I  then  draw  the 
knife  slowly  out,  meantime  pressing  the  fluid  out  of  the  sac.  I  then 
at  once  apply  a  compress,  envelop  the  hand  and  forearm  in  a  wet 
bandage,  to  prevent  any  extensive  motion,  and  have  the  forearm  car- 
ried in  a  sling  four  or  five  days.  Then  the  bandage  is  removed,  the 
small  opening  is  healed,  and  the  ganglion  does  not  usually  return,  as 
it  is  apt  to  do  after  simple  evacuation.  The  entire  hernial  sac  has 
often  been  entirely  removed,  sometimes  successfully  without  subse- 
quent inflammation,  but  at  other  times  with  suppuration  of  the  sheath 
or  loss  of  motion  of  the  finger,  so  that  I  do  not  recommend  this  pro- 
ceeding to  you.  The  difi"erence  in  result  after  extirpation  of  these 
sacs  may  depend  on  whether  there  is  a  large  or  small  communication 
with  the  sheath  of  the  tendon,  or  whether  there  be  none ;  that  the 
latter  state  does  occur  I  have  satisfied  myself  by  examination  of  the 
cadaver ;  but  I  cannot  say  whether  in  such  cases  the  sac  near  the 
sheath  of  the  tendon  is  newly  formed,  or  whether  the  opening,  by 
which  most  of  these  herniae  of  the  sheaths  communicate  with  the  lat- 
ter, has  been  obliterated  in  the  course  of  time. 

The  treatment  of  extensive  dropsies  of  the  sheaths  of  tendons  in 
the  palm  of  the  hand  and  forearm  is  much  more  difficult,  since,  for 
various  reasons,  subcutaneous  discision  is  not  available  here,  and  re- 
sorbents  are  of  little  use  ;  the  only  thing  left  is  to  try  other  methods, 
which  often  at  least  induce  some  suppuration.  Take  into  considera- 
tion then  whether  it  be  really  necessary  to  do  any  thing  severe.  If 
the  disturbance  be  not  so  decided  as  to  greatly  interfere  with  the  pa- 
tient's business,  you  had  better  leave  things  alone.  But,  if  something 
must  be  done,  your  choice  is  almost  limited  to  two  methods,  viz. :  an 
extensive  incision  and  punction,  with  subsequent  injection  of  iodine 


584  CHRONIC   INFLAMMATION   OF   THE  JOINTS. 

"When  you  make  the  punction,  which  I  prefer  to  incision,  yon  should 
choose  a  trocar  of  medium  size,  as  the  fibrinous  bodies  will  not  escape 
through  a  very  fine  one.  You  will  often  have  trouble  in  evacuating 
them  even  through  a  large  canula ;  then  you  will  facilitate  the  opera- 
tion by  injecting  tepid  water  through  the  canula  from  time  to  time,  so 
that  the  increased  amount  of  fluid  will  aid  the  escape  of  the  slippery 
fibrine-kernels.  As  already'  mentioned,  the  quantity  evacuated  is  often 
large.  I  once  took  one  and  a  half  tumblerfuls  from  a  tendon-sac.  After 
all  has  been  removed,  fill  a  syi-inge  Avith  an  ounce  of  a  mixture  of 
equal  parts  of  water  and  tincture  of  iodine,  or  a  corresponding  quan- 
tity of  solution  of  iodine  and  iodide  of  potassium,  and  inject  it  slowly. 
Let  it  remain  in  the  sac  one  to  two  minutes,  and  then  escape  slowly. 
Now  remove  the  canula,  cover  the  wound  with  a  small  compress,  bind 
up  the  hand  and  forearm  carefully,  and  put  it  on  a  splint.  The  patient 
should  stay  in  bed  several  days.  The  operation  is  followed  by  a  con- 
siderable swelling,  due  to  collection  of  fluid  as  a  result  of  acute  in- 
flammation of  the  serous  sac.  If  the  tension  become  decided,  we 
should  remove  the  dressings,  carefully  close  the  punctiu-e  with  plaster, 
then  paint  the  swelling  with  strong  tincture  of  iodine.  In  the  more 
favorable  cases,  the  swelling  will  then  gradually  subside,  become  less 
painful,  and  in  the  coiu-se  of  two  to  three  weeks  disappear  entirely.  In 
many  other  cases,  however,  there  will  be  some,  even  if  very  temporary, 
suppuration,  which  may  be  checked  and  subdued  with  ice.  In  the  worst 
cases  there  may  be  extensive  suppuration  of  the  sheath  with  necrosis 
of  the  tendon,  and  its  results.  Of  course,  opening  the  whole  sac  nat- 
urally induces  suppuration. 

On  this  occasion  I  must  again  repeat  that  there  may  be  hernial 
protrusions  from  the  capsule  of  the  joint,  just  as  from  the  sheaths  of 
the  tendons,  wliich  may  become  dropsical  without  the  dropsy  extend- 
ing to  the  entire  synovial  membrane.  The  fibres  of  the  capsule  sepa- 
rate, and  the  synovial  membrane  passes  between  them  into  the  sub- 
cutaneous tissue  in  form  of  the  finger  of  a  glove.  Although  such 
formations  of  round,  pedunculated,  long,  wreath-like,  and  other  shapes 
may  develop  from  any  joint,  they  are  chiefly  met  in  the  knee,  hand, 
and  elbow ;  in  the  latter  I  have  often  seen  these  isolated  dropsies  of 
hernias  of  the  synovial  sac  communicating  with  the  joint ;  they  are 
accompanied  by  slight  stifi'ness  of  the  joint. 

I  urgently  warn  you  against  operation  on  these  ganglia  of 
the  joints ;  this  operation  may  be  followed  by  suppuration  ot  the 
joint. 

Cartilaginous  bodies,  enchondromata,  sometimes  even  ossifying, 
occur  in  the  tufts  of  the  sheath  of  the  tendons.     Lipoma  (Z.  arhores- 


GANGLIA  OF  THE  JOINTS. 
Fig.  98. 


585 


d  - 


Dcniial  protrusions  of  the  synovial  membrane  of  the  knee-joint  posteriorly  (after  W.  Grvber). 
A.a.M.  seniimerabranosiiP  :  &,  M.  biceps  ;  c  d,  M.  gastrocnemius ;  e,  M.  plantaris ;  //,  sy- 
novial hernias. — B.  a,  capsule  of  knee-joint ;  c  ti,  MI  gastrocnemius ;  //,  synovial  hernia. 

ce7is  of  Jl  Midler)  has  also  been  seen  in  the  villi.     The  tumors  should 
only  be  removed  Avhen  they  cause  decided  inconvenience. 


Plere  we  shall  also  speak  of  fistulas  and  chronic  dropsies  of  the 
siibcutaneous  mucous  hursce.  If  one  of  these  bursas  be  opened  by  a 
simultaneous  skin-wound,  we  often  have  protracted  suppuration  from 
the  sac,  which  is  not  dangerous,  it  is  true,  although  there  may  be  an 
extension  of  the  suppuration  to  the  subcutaneous  cellular  tissue, 
which,  from  its  duration,  may  prove  very  annoying ;  even  after  the 
greater  part  of  the  wound  is  healed,  a  fine  opening  remains;  through 
tliis  a  probe  may  be  passed  into  the  sac  ;  a  moderate  quantity  of  serum 
is  daily  evacuated  through  this  fistula  of  the  mucous  bursce.  We  may 
sometimes  heal  these  fistulre  by  cauterization  with  nitrate  of  silver  and 
compression  by  adhesive  plaster ;  but  in  some  cases  they  are  very  ob- 
stinate. Then  you  iiiay  attempt,  by  injecting  tincture  of  iodine,  to 
excite  a  more  intense  suppuration  of  the  inner  well  of  the  sac,  and 
thus  cause  it  to  atroph}'  or  become  adherent ;  but  a  quicker  way  is  to 
introduce  a  blunt-pointed  knife  through  the  fistula  and  slit  up  the 
sac  and  superjacent  skin,  so  as  to  expose  the  whole  interior ;  granulac 


586  CHRONIC  INFLAMMATION   OF  THE  JOINTS. 

tions  will  gradually  spring  up,  and  the  wound  will  finally  Leal.  I  de- 
cidedly prefer  this  method. 

Dropsies  of  the  subcutaneous  miccous  hursm  are  perfectly  analo- 
gous to  the  above-described  dropsies  of  the  sheaths  of  tendons.  Per- 
haps they  may  occasionally  be  caused  by  pressure  or  blows,  but  in 
many  cases  it  is  impossible  to  find  any  exciting  cause.  Although 
dropsies  may  occur  in  any  of  the  constant,  or  occasionally  in  newly- 
formed  subcutaneous  mucous  bm-sje,  they  are  particularly  frequent  in 
the  biu-sa  praepatellaris,  which,  according  to  JLhihart,  often  consists 
of  two  or  three  mucous  bursas,  lying  over  each  other,  sometimes  en- 
tirely closed,  at  others  communicating  with  each  other.  Dropsy  of 
the  bursa  prgepatellaris  is  very  easy  to  recognize,  for  the  tumor,  which 
attains  about  the  size  of  a  small  apple,  is  very  evidently  situated  on 
the  patella,  and  examination  plainly  shows  that  the  sac  containing  the 
fluid  does  not  ccmmunicate  with  the  knee-joint.  This  disease  often 
begins  acutely  or  subacutely ;  the  fluid  collects  rapidly,  the  swelling 
is  painful,  the  skin  over  it  is  red,  and  the  patient  cannot  walk  well. 
The  terminations  are  various ;  there  is  often  entire  reabsorption  of  the 
fluid,  and  a  return  to  the  normal  state  ;  in  other  cases  the  reabsorp- 
tion is  partial,  the  acute  symptoms  subside,  and  the  state  gradually 
becomes  chronic.  Rupture  of  the  sac  is  one  of  the  rarer  terminations ; 
this  may  be  subcutaneous ;  the  fluid  is  emptied  into  the  subcutaneous 
cellular  tissue,  and  induces  diffuse  inflammation.  Rupture  of  both  sac 
and  skin  is  the  rarest  resxilt ;  the  disease  then  runs  the  course  of  a 
punctured  or  incised  wound  of  the  bursa,  of  which  we  have  already 
spoken. 

The  form  of  the  disease  which  is  chronic  from  the  start  is  more 
frequent  than  the  acute.  It  begins  slowly,  without  pain,  and  is  more 
frequent  in  old  than  in  young  persons.  In  England  this  chronic 
dropsy  of  the  bursa  praepatellaris  is  called  "housemaid's  knee  ;"  there 
it  is  said  to  occur  particularly  among  the  servant-women  who  have  to 
scrub  the  stairs  on  their  knees.  But  it  seems  to  me  very  doubtful 
whether  this  has  any  effect  on  the  occurrence  of  the  disease,  for  it  has 
been  shown  by  many  anatomists  that  in  a  kneeling  position  the 
weight  of  the  body  does  not  come  on  the  patella,  but  on  the  condyles 
of  the  tibia.  To  bring  the  anterior  surface  of  the  patella  on  the 
ground,  it  would  be  necessary  to  he  almost  on  the  belly. 

The  contents  of  these  dropsical  sacs  are  much  less  tenacious  than 
those  of  sheaths  of  the  tendons ;  but  not  unfrequently  these  sacs  also 
contain  fibrinous  bodies,  which,  on  palpation,  give  a  friction-sound, 
like  that  made  by  starch-meal  when  rubbed  between  the  fingers.  In 
the  course  of  time  the  sac  itself  is  thickened,  the  more  so  the  older 
the  disease. 


HOUSEMAID'S   KNEE.  587 

Only  the  acute  cases  come  under  the  surgeon's  notice.  They 
should  be  treated  as  follows :  First  of  all,  the  patient  should  be  kept 
quiet;  then  paint  the  swelling  freely  with  tincture  of  iodine.  Under 
this  treatment  the  dropsy  generally  subsides  rapidly;  any  remaining 
fluid  you  may  attempt  to  remove  by  compression  with  adhesive  plas- 
ter or  bandages  ;  or  you  may  from  the  first  employ  compression  with 
wet  bandages,  or  envelop  the  knee  in  wet  compresses;  mercurial 
salve  and  mercurial  plaster  are  also  of  good  service. 

Chronic  dropsy  of  the  bursa  pr^epatellaris  usually  causes  so  little 
inconvenience  that  it  is  generally  of  long  standing  before  it  comes  to 
the  surgeon's  notice.  Most  persons  scarcely  have  their  movements 
impaired  by  the  disease ;  others  say  that  they  tire  sooner  than  for- 
merly in  the  affected  limb.  The  aifection  is  usually  limited  to  one 
side,  but  may  attack  both.  It  is  generally  very  difiicult  to  cure  chronic 
dropsy  of  the  bursa  pr»pateUaris  by  the  remedies  above  mentioned. 
The  trouble  may  be  removed  by  operation.  Tapping  is  no  more  a 
radical  cure  here  than  in  other  dropsies,  as  new  fluid  collects  ;  for  tap- 
ping to  prove  efficacious  it  should  be  followed  by  injection  of  tincture 
of  iodine.  This  is  free  from  danger,  if  the  patient  subsequently  keeps 
quiet ;  the  result  is  generally  a  radical  cure.  Another  treatment  is 
splitting  up  the  sac,  which  is  followed  by  its  suppuration.  If  the  sac 
be  very  thick,  it  is  justifiable  to  extirpate  it  entirely,  which,  however, 
should  be  done  very  carefully  to  avoid  injuring  the  adjacent  capsule 
of  the  joint.  JR.  Vblkmann  has  recommended  a  plan  of  treatment 
which  I  have  often  employed  with  good  results,  i.  e.,  forced  compres- 
sion ;  a  well-padded,  hollow  spHnt  of  tin  or  wood  is  apphed  to  the 
back  of  the  knee,  and  the  knee  is  drawn  as  firmly  as  jDossible  against 
it  by  means  of  flannel  bandages ;  this  compression,  which  usuallv 
causes  oedema  of  the  foot,  and  sometimes  severe  pain,  should  be  con 
tinued  several  days.  Reabsorption  results,  in  two  or  three  days,  in 
small  hygromata ;  in  six  or  eight  days,  in  large  old  ones.  I  have  seen 
very  good  results  from  this  plan,  not  only  in  hygroma  praepateHare, 
but  also  in  dropsy  of  the  knee ;  in  dropsy  of  the  sheaths  of  the  ten- 
dons it  rarely  does  any  good. 

[In  chronic  synovitis,  the  most  efficient  form  of  compression  is 
by  the  elastic  bandage,  or  by  moist  sponges  kept  in  place  by  a 
bandage.  This  pressure  can  only  be  continued  from  ten  to  twenty- 
five  minutes  ;  in  the  interval  an  ordinary  bandage  may  be  applied. 
I  have  seen  complete  recovery,  even  after  two  or  three  applications 
of  this  dressing.  Massage,  also,  which  may  be  applied  energetically 
in  such  cases,  is  an  excellent  remedy  ;  in  some  respects  even  prefer- 
able to  compression.  It  induces  a  rapid  sero-fibrinous  inflammation, 
which,  with  the  general  increase  of  the  blood  and  lymph  cu-culatiou, 


538  CHRONIC   INFLAMMATION   OF  THE  JOINTS. 

induces  absorption  of  the  fluid  in  the  joint.  Often  massage  and 
compression  may  be  combined,  and,  in  the  interval,  the  limb  kept 
immovable  by  a  splint. 

"When  we  resort  to  injections  into  the  joints,  we  may  try  two-  to 
four-per-cent.  solutions  of  carbolic  acid,  as  being  less  dangerous 
than  iodine,  but  they  also  are  unreliable.  The  solution  should  be 
brouo-ht  in  contact  with  the  entire  surface  of  the  synovial  membrane. 
With  this  object,  the  medicament  should  be  introduced  to  the  joint 
through  a  large  trocar,  and  motions  of  flexion  and  extension  made, 
and  the  synovial  sac  distended  by  the  pressure  of  the  injection  ;  the 
fluid  should  be  changed  several  times,  and  finally  allowed  to  escape, 
or  aspirated  by  depressing  the  irrigator.  Then  the  opening  should 
be  accurately  closed,  and  a  Lister''s  dressing  and  a  splint  applied. 
Reaction  may  be  severe,  or  there  may  be  symptoms  of  poisoning 
from  absorption  of  carbolic  acid,  with  symptoms  of  dangerous  col- 
lapse. In  other  cases  the  effect  of  the  carbolic-acid  injection  is  in- 
suflicient,  and  the  fluid  reaccumulates. 

Dedat,  a  French  physician,  who  published  a  large  book,  in 
1865,  on  the  internal  and  external  employment  of  carbolic  acid, 
claims  that  the  dangerous  symptoms  of  poisoning,  and  the  irritant 
local  effects  observed  from  its  use,  are  due  to  impurities,  and  to  the 
presence  of  cresylic  acid  and  other  corrosive  substances,  which  he 
claims  may  be  removed  by  special  modes  of  preparation. 

At  present,  by  careful  antiseptic  treatment,  ganglia  may  be 
divided  their  whole  length,  the  contents  evacuated,  the  cavity 
washed  with  a  four-per-cent.  solution  of  carbolic  acid,  drained,  and 
a  Lister'' s  dressing  applied.  It  is  best  to  continue  compression  for 
some  time  after  this  operation,  by  applying  a  plaster  dressmg  over 
the  forearm  and  hand,  and  cutting  an  opening  at  the  seat  of  the 
ganglion,  which  may  be  covered  by  a  compress  and  pressure  made 
by  an  elastic  bandage,  while  the  plaster  splint  protects  the  limb 
from  constriction,  and  keeps  it  perfectly  quiet.  After  a  week  the 
dressing  may  be  removed,  the  wound  being  then  healed  and  the 
fluid  not  returning.  Formerly  extirpation  of  a  ganglion  was  con- 
sidered a  dangerous  operation,  and  correctly  so,  as  one  could  not 
know  beforehand  whether  extensive  suppuration  of  the  sheaths  of 
the  tendons,  with  all  its  dangers,  would  follow  ;  but  antisepsis  al- 
most certainly  prevents  this.  Hence,  by  its  aid,  we  may  undertake 
removal  of  obstinate  recurrent  ganglia,  even  if  the  sac  communi- 
cates with  the  sheath  of  the  tendon.  Under  such  circumstances, 
the  opening  in  the  tendon-sheath  should  be  closed  with  fine  catgut, 
and  the  limb  kept  immovable.] 


CHRONIC   INFLAMMATION   OF  THE   JOINTS.  589 


LECTURE    XL. 

C.  Chronic  Rlieumatic  Iiiflammation  of  tLe  Joints.— Arthritis  Deformans.— Malum 
Coxse  Senile.  —  Anatomy,  Different  Forms,  Symptoms,  Diagnosis,  Prognosis, 
Treatment.— Appendix  I. :  Loose  Bodies  in  the  Joints  :  1.  Fibrinous  Bodies ; 
2.  Cartilaginous  and  Bony  Bodies ;  Symptomatology,  OiJerations.— Appendix  II.: 
Neuroses  of  the  Joints. 

0.  CHEGNIC  RHEUMATIC  INFLAMMATION  OF  THE  JOINTS— CHRONIC 
ARTICULAR  RHEUMATISM— ARTHRITE  SfiCHE- RHEUMATIC  GOUT- 
ARTHRITIS   DEFORMANS— MALUM  SENILE  COX^. 

5rou  will  be  frightened  at  this  crowd  of  names,  which  all  refer  to 
the  same  anatomical  morbid  changes,  and  you  will  rightly  ask,  Why 
so  many  names  for  the  same  thing?  When  a  disease  has  received  so 
many  designations,  it  is  often  a  sign  that  its  nature  is  not  correctly 
understod,  or  that  there  have  been  various  views  regarding  it  at  dif- 
ferent times ;  but  this  is  not  the  case  here,  for  the  process  has  always 
been  regarded  in  the  same  way,  and  all  observers  fully  agree  in  their 
decisions.  It  mil  be  best  to  commence  with  the  anatomy.  The  dis- 
ease chiefly  aiiects  the  cartilage,  secondarily  the  synovial  membrane 
also,  as  well  as  the  periosteum  and  bone  ;  in  most  cases  the  cartilage 
is  primarily  attacked.  The  changes  that  we  find  in  the  cartilage  are 
as  follows :  In  some  places  it  becomes  nodular,  then  rough  on  the 
surface,  may  be  pulled  into  filaments,  and,  when  the  disease  is  far  ad- 
vanced, it  is  altogether  absent  in  places,  leaving  the  bone  exposed 
quite  smooth  and  polished.  If  you  examine  the  cartilage  that  is  broken 
up  into  filaments,  you  will  £nd  even  microscopically  that  the  intercel- 
lular substance,  which  should  be  homogeneous,  is  filamentary.  You 
also  find  that  the  cartilage-cavities  are  enlarged  and  contain  cells, 
which  are  dividing  up ;  but  these  cells  are  not  so  small  or  slightly 
developed  as  is  customary  in  cell-foimations  occurring  in  inflamma- 
tions ;  they  are  well  formed,  and  sometimes,  from  a  somewhat  thick- 
ened membrane,  are  recognizable  as  new  cartilage-cells  ;  the  changes 
progress  very  slowly,  and  the  newly-formed  cells  go  on  to  a  rather 
higher  grade  of  histological  development  than  in  the  above-described 
forms  of  inflammation  (Fig.  99) ;  the  intercellular  substance  does  not 
soften,  as  in  inflammations  generally,  but  breaks  up  into  filaments ; 
this  is  a  characteristic  peculiarity  of  the  disease,  but  there  are  also 
various  others.  The  rough  cartilage  does  not  resist  the  friction  of  the 
articular  surfaces,  but  is  gradually  rubbed  through,  and  is  worn  down 
to  the  bone. 

Immediately  under  the  cartilage  there  is  always  a  layer,  even  if  it 
be  very  thin,  of  compact  bony  substance;  lying  next  to  this  are  the 


590 


ARTHRITIS  DEFORMANS. 


spongy  ends  of  the  epiphyses;  after  the  cartilage  is  destroyed  the 
friction  aflfects  this  layer,  and,  as  a  result  of  the  mechanical  irritation, 
new  bony  substance  is  formed  in  this  layer ;  under  the  point  of  irrita- 
tion the  medulla  of  the  spongy  substance  ossifies  to  a  slight  extent. 
The  adjacent  bones  are  gradually  ground  off  by  the  motions  in  the 


Pia.  99. 


Degeneration  of  the  cartilage  in  arthritis  deformans:  a.  fatty  decreneration  of  the  cartilag 
cells.    Magnified  350  diameters,  after  0.  Weber. 


joint,  but,  as  the  friction  constantly  causes  the  formation  of  new  bone, 
the  part  ground  off  usually  remains  firm  and  smooth,  as  the  hard- 
ening always  precedes  the  atrophy  from  friction ;  hence,  if  the  joint 
remain  movable,  a  considerable  portion  of  the  bone  may  be  worn  off, 
and  the  defective  articular  surface  of  the  bone  may  still  remain  smooth. 
In  the  hip,  these  ground  surfaces  are  at  the  upper  surface  of  the  head 
of  the  femur,  and  in  the  acetabulum ;  in  the  knee,  the}''  are  on  the 
condyles,  etc.  In  these  changes  the  neck  of  the  femur  may  be  cov- 
ered with  osteophytes  in  some  places,  while  induration  goes  on  at  the 
smooth  surfaces.  The  neck  of  the  femur  may  be  surrounded  by  osteo- 
phytes, and  thus  acquire  a  characteristic  shape.     This  wiU  sometimes 


CHRONIC  INFLAMMATION   OF  THE   JOINTS.  591 

coine  up  in  very  peculiar  forms;  in  one  place,  atrophy,  in  another, 
formation  of  bone,  in  the  same  case,  alongside  of  each  other  in  the 
same  bone.  The  disease  not  unfrequently  begins  as  nodular  prolifera- 
tion of  cartilage,  and  ends  with  atrophy  of  cartilage.  I  think  you  are 
already  acquainted  with  this  combination  of  atrophy  and  new  forma- 
tion in  chronic  inflammatory  processes ;  only  call  to  mind  caries,  the 
type  of  ulcerative  processes ;  there  we  also  saw  destruction  going  on 
at  the  ulcerated  surface,  and  extensive  new  formations  around  it. 

The  above  changes  in  the  cartilage  and  bone  are  accompanied  by 
some  in  the  synovial  membrane,  which,  however,  do  not  differ  much 
from  those  in  chronic  dropsy  of  the  joint;  this  contains  a  slightly-in- 
creased amount  of  synovia,  which  is  cloudy,  thin,  and  mixed  with  the 
ground-down  particles  of  cartilage.  The  membrane  itself  is  thick- 
ened, slightly  vascular,  the  elongated  tufts  alone  have  more  vascular 
loops  in  then-  apices.  Parts  about  the  joint  may  participate  in  the  in- 
flammation— periosteum,  tendons,  and  muscles.  These  occasionally 
ossify  very  slowly,  so  that  the  ends  of  the  bones  are  often  covered  with 
bony  masses  ;  this  bony  proliferation  is  sometimes  very  extensive.  Tlie 
form  of  these  osteophytes  is  very  different  from  those  with  which  we 
are  already  acquainted ;  they  are  flat  and  roundish,  not  shaped  like 
pointed  stalactites,  but  look  like  a  fluid  which  had  been  poured  out 
and  stiffened  while  flowing ;  moreover,  they  are  not  so  porous  as  other 
osteophytes,  but  all  the  layers  are  of  more  compact  bony  substance. 
From  these  peculiarities,  which  you  will  at  once  notice  on  seeing  a 
series  of  preparations,  the  appearance  of  this  variety  of  articular  dis- 
ease is  even  exteriorly  so  characteristic  that,  on  seeing  a  macerated 
preparation  of  the  bones,  you  would  at  once  recognize  the  disease 
without  knowing  any  thing  of  the  special  case. 

In  this  disease  the  new  formation  of  bone  probably  takes  such  a 
peculiar  form,  first,  because  the  process  of  development  is  so  slow ; 
secondly,  because  here  the  ossification  is  not  preceded  by  any  special 
vascularity,  as  in  osteophytes  forming  during  the  union  of  fractures 
in  caries,  necrosis,  ostitis,  etc. ;  if  a  tissue  be  very  vascular  when  it 
ossifies,  a  porous  bony  substance  must  be  formed,  for  the  more  vessels 
there  are  the  more  holes  there  will  be  in  the  bones.  But  in  arthritis 
defomians  the  ossification  is  not  preceded  by  any  considerable  new 
formation  of  vessels,  the  tissues  ossify  mostly  just  as  they  are ;  perios- 
teum, tendons,  even  the  capsule,  ligaments,  and  muscles,  and  all  this 
goes  on  very  slowly ;  this  is  why  the  bone  formed  is  firmer.  Sometimes 
also  in  the  Adcinity  of  the  bone  in  the  midst  of  the  subserous  cellular 
tissue  detached  points  of  bone  form,  which  for  a  long  time  remain 
isolated  round  pieces ;  subsequently  they  may  perhaps  unite  with  the 
other  bony  masses;  then  they  look  as  if  glued  on,  and  from  the  form 


592 


POLYARTICULAR   CHRONIC   RHEUMATISM. 


of  the  bony  growth  we  may  often  tell  the  course  of  its  formation. 
These  periarticular  bony  formations  may  cause  entire  dislocation  of 
the  joint  and  force  it  into  an  abnormal,  half-luxated  position ;  they 


Fio.  100. 


Fia.  101. 


Fig.  102. 


Figs.  100  and  102,  osteophytes  In  ar- 
thritis deformans,  i'ig.  100,  low- 
er end  of  the  humerus,  dimin- 
ished; a,  osteophytes;  b,  smooth- 
ed end  of  the  hone. 


Fig.  101,  carious  elbow-joint, 
fungous  inlliimm.ation  of 
the  joints,  stalactite-Iiko 
osteophytes,  diminished. 


Fig.  102,  08  meta- 
carpi,  I  a  and 
b,  as  in  Fig.  100. 


may  even  render  it  entirely  immovable.  Sometimes  these  osseous 
formations  grow  into  the  joint,  loosen  from  their  attachments,  and 
become  loose  bodies  in  the  joint ;  of  which  we  shall  speak  hereafter. 
Lastly,  chronic  dropsy  may  accompany  this  affection  also,  and  you 
may  readily  understand  that,  from  all  these  concurring  circumstances, 
the  joint  may  become  so  deformed  as  justly  to  deserve  the  name 
*'  arthritis  deformans."  But,  I  again  repeat,  that  all  these  pathologi- 
cal changes  never  lead  to  suppuration. 

We  now  come  to  the  chnical  appearance  of  this  peculiar  disease. 
According  to  my  experience,  I  should  distinguish  three  forms  of  the 
disease  :  one,  which  is  usually  polyarticular  and  accompanied  by  con- 
traction of  the  muscles ;  a  second,  which  comes  in  one  joint  in  young 
and  middle-aged  persons ;  and  a  third,  which  only  occurs  in  old  age. 

1.  Polyarticular  chronic  rheumatism  (arthrite  seche,  rheumatis- 
rrms  nodosus,  rheumatic  gout)  attacks  young  or  middle-aged  persons ; 
it  is  more  frequent  in  women  than  in  men,  and  in  poor  than  in  rich 
[)eople ;  badly-nourished,  aneemic  persons  are  especially  liable  to  it ; 


CHRONIC   INFLAMMATION   OF  THE  JOINTS.  593 

It  may  originate  in  acute  articular  rheumatism  or  in  a  gonorrhoea!  in- 
flammation of  the  joint ;  after  the  termination  of  the  acute  or  sub« 
acute  disease  of  the  joints,  stiflFness,  pain,  and  swelhng,  remain  in  some 
of  the  joints,  most  frequently  in  the  knees.  But  the  disease  may  be 
chronic  from  the  start,  with  moderate,  unsteady  pains  in  the  joints. 
At  first  the  patients  use  their  hmbs  very  well ;  but  in  the  course  of 
months  and  years  the  mobihty  gradually  decreases  ;  after  exertion  and 
catching  cold,  subacute  dropsies  of  the  joint  come  on,  a  part  of  the  fluid 
may  be  reabsorbed ;  but  the  joint  always  remains  somewhat  stifier  after 
every  exacerbation,  sometimes  also  it  is  enlarged.  In  the  mornino- 
when  the  patient  rises,  the  limbs  are  so  stifi"  as  to  be  scarcely  mov- 
able, though,  after  a  few  efibrts,  he  gets  along  better  for  the  rest  of 
the  day,  but  toward  evening  the  joint  again  becomes  painful.  Now  a 
new  symptom  gradually  arises ;  the  muscles  atrophy,  the  legs  become 
thinner,  and  are  fixed  in  a  flexed  position  ;  the  atrophying  muscles 
have  great  incHnation  to  contract,  which  is  constantly  favored  by  the 
abnormal  position  of  the  joint.  Meantime,  the  general  health  of  the 
patient  remains  perfect;  his  appetite  and  digestion  are  good;  he 
grows  fat,  and  only  has  fever  when  there  is  an  exacerbation  of  the 
joint-trouble.  The  joint  is  not  very  painful  on  pressure ;  if  it  be 
movable,  we  may  feel  and  hear  friction  and  grating  sounds.  This  goes 
on  for  years.  Finally,  ihe  patients  emaciate  greatly,  the  joints  be- 
come deformed  and  stiS",  or,  as  the  laity  say,  "all  drawn  up;"  if  the 
disease  be  in  the  hips  or  knees,  they  are  bed-ridden,  but  with  proper 
care  may  live  for  years;  the  knee,  hip,  wrist,  ankle,  and  shoulder 
joints,  are  most  frequently  attacked. 

2.  Arthritis  deformans  is  almost  always  monarticular,  rarely  it 
attacks  similar  joints  on  both  sides ;  it  occurs  in  persons  otherwise 
healthy  and  strong ;  I  have  seen  it  somewhat  more  frequently  in  men 
than  in  women.  This  form  received  its  name  from  the  fact  that  in  it 
the  periarticular  periosteal  formation  of  bone  and  the  ground  surfaces 
become  so  extensive  that  the  joint  is  deformed.  I  have  seen  the  dis- 
ease once  in  the  hip,  in  both  knees  of  the  same  person,  once  in  the 
foot  and  elbow,  and  twice  in  the  shoulder.  Usually  there  is  no  assign- 
able cause  ;  in  some  cases  it  was  preceded  by  luxations  or  sprains. 
These  joints  are  generally  painless,  stiff,  dropsical,  and  often  contain 
loose  bony  bodies,  and  the  synovial  membrane  may  be  covered  with 
fatty  tufts. 

3.  Malum  coxce  senile.  If  the  disease  attack  old  people,  it  is 
usually  somewhat  milder  than  the  bad  forms  of  chronic  rheumatism. 
The  hip  is  the  chief  seat  of  the  disease,  hence  the  name  "  malum 
coxae  senile,"  but  it  also  comes  in  the  shoulder,  knees,  and  elbows,  but 
especially  in  the  fingers  and  great  toes  of  old  people.     Its  commence- 

89 


594 


MALUM   COX^   SENILE. 


ment  is  usually  chronic,  there  is  little  pain,  but  much  stiffness ;  more 
rarely  the  initial  stage  is  acute ;  at  first,  the  patients  often  complain 
only  of  stiffness,  especially  in  the  morning ;  after  the  joint  has  been 
used,  it  grows  more  movable,  the  friction  is  often  so  marked  that  the 
patient  calls  the  physician's  attention  to  it.  Attacks  with  severe  pain 
and  slight  fe  /er  are  most  common  where  the  fingers  are  the  chief  seat 
of  the  disease ;  in  the  course  of  years  the  finger-joints  are  much  de- 
formed. The  great  toe  is  dislocated  outwardly,  and  the  bony  deposits 
on  the  head  of  the  first  metatarsal  bone  become  very  prominent.  If 
the  disease  develop  in  the  hip,  the  patients  limp  slightly ;  in  old  per- 
sons  the  bony  deposits  are  generally  insignificant ;  but  the  thigh  is 
gradually  shortened,  from  the  wearing  down  of  the  head  of  the  femur 
and  the  acetabulum ;  the  muscles  atrophy,  the  hip  gradually  grows 
stiff;  but  this  may  not  take  place  for  years.  The  disease  is  much 
more  frequent  in  men  than  in  women,  and  thin  people  are  most  liable 
to  it.  It  is  rarely  accompanied  by  disease  of  other  organs,  particu- 
larly the  internal  ones,  but  the  affection  is  not  unfrequently  found  in 
persons  predisposed  to  chalky  deposits  and  abnormal  ossifications; 
rigidity  of  the  arteries,  ossification  of  the  ribs  and  intervertebral  car- 
tilages, and  anterior  spinal  ligaments,  are  often  present  in  patients  suf- 
fering from  malum  senile. 

The  diagnosis  is  easy;  after  the  above  description  you  w^ould  not 
readily  mistake  the  disease.  If  the  affection  attack  a  single  joint  in 
a  young  person,  we  may  at  first  be  doubtful  if  it  is  a  case  of  fungous 
inflammation  or  of  arthritis  deformans ;  but,  after  further  observation, 
the  diagnosis  will  be  easy.  In  the  later  stages  it  might  also  be  mis- 
taken for  fungous  inflammation,  with  caries  sicca,  where  we  also  find 
atrophy  of  the  muscles  and  friction  in  the  joint,  and  which  also  runs 
a  very  chronic  course  In  young  and  otherwise  healthy  subjects ;  but  in 
caries  sicca  there  are  never  such  extensive  deposits  around  the  joint, 
as  in  arthritis  deformans,  and,  even  when  of  long  duration,  the  latter 
shows  no  tendency  to  suppuration.  When  the  chronic  rheumatic 
articular  inflammation  occurs  on  both  sides,  or  attacks  several  joints 
at  once,  and  is  accompanied  by  the  reflex  contraction  of  the  muscles 
due  to  irritation  of  the  synovial  membrane,  the  disease  cannot  be  mis- 
taken. Rheumatismus  nodosus  is  often  confounded  with  gout,  because 
the  effect  of  the  two  diseases  on  the  hands  and  feet  is  somewhat  simi- 
lar. But  gout  is  so  characterized  by  its  specific  attacks,  and  by  the 
excretion  of  uric  acid,  that  it  should  be  regarded  as  a  different  disease ; 
we  have  already  spoken  about  this. 

The  prognosis  of  polyarticular  rheumatism  is  very  bad  as  regards 
recovery ;  when  it  attacks  old  persons,  I  consider  it  entirely  incurable. 
In  young  patients,  by  very  careful,  persistent  treatment,  the  disease 


CHRONIC  INFLA3IMATI0N   OF  THE   JOINTS.  596 

tnaj'  sometimes  be  arrested  at  a  certain  point,  and  slight  improvement 
be  attained;  but  even  this  is  very  difficult,  only  a  few  cases  are  entire- 
ly cured.  These  unfavorable  results  are  due  to  the  anatomical  prod- 
ucts of  this  disease ;  the  worn-down  cartilage  and  bone  are  not  re- 
placed, the  bony  deposits  are  not  reabsorbed,  they  are  too  firm  and 
solid ;  the  nutrition  of  the  muscles  fails  to  be  excited  by  the  natural 
motion  of  the  limbs,  for  they  are  almost  too  weak  to  put  in  action  the 
stiff  limbs.  When  you  have  such  a  patient  to  treat,  arm  yourself  with 
patience,  and  be  not  surprised  if  he  consults  first  one  then  another 
physician,  and  finally  all  the  quacks  about,  and  lastly  blames  you  for 
the  origin  and  extent  of  his  disease. 

Of  course,  even  these  patients  must  be  treated ;  the  surgeon  cannot 
pick  out  the  curable  cases,  the  incurable  and  d3ing  also  have  claims 
for  his  aid,  and  -where  we  cannot  aid  we  should  at  least  try  to  alleviate 
and  mitigate  the  disease.  Chronic  rheumatic  inflammation  of  the 
joints,  by  its  simultaneous  occurrence  at  different  points,  shows  that 
it  is  not  due  to  a  local  injury,  acting  on  a  special  joint,  but  frequently 
at  least  to  a  constitutional  cause;  the  enigmatical  rheumatic  diathesis 
is  often  blamed  for  the  tendency  to  inflammation  of  the  serous  mem- 
branes, and  exudations  in  the  joints  and  muscles,  hence  we  employ 
antirheumatic  remedies.  The  persistent  emploj'^ment  of  iodide  of  pot- 
ash, of  colchicum  and  aconite,  of  diaphoretics  and  diuretics,  is  rec- 
ommended, although  little  benefit  has  been  observed  from  them  ;  but 
there  is  nothing  else  that  is  better,  at  least  nothing  to  act  specially  on 
the  rheumatism.  Besides  these  remedies,  and  those  called  for  by 
special  peculiarities  of  the  case,  warm  baths  are  highly  recommended, 
particularly  the  indifferent  thermal  baths :  Wildbad  in  Wurtemberg, 
Wildbad-Gastein,  Baden  in  Zurich,  Baden-Baden,  Teplitz,  Ragaz  in 
St.  Gallen ;  besides  these,  salt-baths  may  be  given,  especially  where 
there  is  commencing  muscular  atrophy.  Special  attention  should  be 
paid  to  the  climate  of  these  watering-places,  for  all  of  these  patients 
are  very  sensitive  to  cold,  damp  weather.  Hot  sulphur  springs  should 
be  tried  very  carefully,  and  given  up  at  once  if  a  subacute  attack  occur 
after  their  use.  If  the  patient  live  in  a  climate  where  the  winter  is 
cold  and  damp,  he  should  be  sent  to  winter  in  Italy,  but,  for  fear  of 
possible  cold  weather,  should  only  go  to  places  like  Nice,  Naples,  Pa- 
lermo, etc.,  where  the  houses  are  well  built.  Damp  dwellings  should 
be  most  carefully  shunned.  The  patient  should  keep  warm,  always 
wear  wool  next  the  body,  and  the  affected  joints  should  be  wrapped 
in  flannel.  V/ater-cures  are  much  recommended,  and  show  some  suc- 
cessful cures ;  when  sensibly  used  by  physicians,  and  not  simply  by 
proprietors  of  the  establishments,  they  are  certainly  appropriate,  and 
often  prove  peculiarly  advantageous  by  hardening  the  patient,  and 


596  TREATMENT   OF   TOLYARTICULAR   RHEUMATISM. 

renderino-  him  less  susceptible  to  external  influences,  especially  tc 
catchino-  cold ;  moreover,  drinking  quantities  of  water,  and  the  wrap- 
ping up  after  the  baths,  have  a  diuretic  and  diaphoretic  effect ;  besides, 
this  mode  of  treatment  has  the  advantage  that  patients  will  follow  it 
out  conscientiously  and  perseveringly,  while  they  soon  tke  of  taking 
medicines ;  as  is  well  known,  hydropaths  soon  become  enraptured  with 
the  system,  and  are  very  satisfactory  patients  even  where  the  treair 
ment  is  unsuccessful.  Hence,  if  the  patient  be  not  too  much  debili- 
tated and  ha%^e  no  disinclination  to  the  treatment  (as  sometimea 
happens),  it  should  be  tried,  but  should  be  continued  at  least  a  year 
to  be  of  any  real  benefit.  Russian  vapor-baths  have  also  been  success- 
ful in  some  cases,  as  have  also  pine-needle  baths.  In  badly-nourished 
patients  the  disease  has  also  been  cured  by  cod-liver  oil,  quinine,  and 
iron.  For  local  treatment  we  may  rub  in  various  things — the  friction 
is  doubtless  the  most  important  part  of  the  apphcation ;  you  may  use. 
iodine-ointment,  simple  grease,  volatile  liniment,  etc.  Strong  deriva- 
tive remedies  are  of  no  use,  and  even  tincture  of  iodine  is  only  bene 
ficial  in  subacute  attacks,  in  which  cases  blisters  may  also  be  tried 
Be  careful  about  applying  powerful  irritants  to  the  joint ;  in  chronic, 
torpid  cases  douches  may  prove  very  efficacious ;  even  hot  or  steam 
douches  and  local  sulphur-baths  have  proved  beneficial  in  some  cases ; 
but  in  other  cases  even  the  mildest  shower-bath,  from  a  foot  high, 
proves  too  irritating;  we  cannot  always  prophesy  the  effect,  the 
patient  should  try  it  carefully  under  the  supervision  of  the  surgeon  ; 
as  soon  as  pain  is  excited,  the  douche  should  be  stopped,  and,  after  a 
period  of  rest,  be  tried  with  new  precautions ;  if  the  pains  come  on 
again,  and  increase,  the  douches  had  best  be  given  up. 

Should  the  limbs  be  kept  at  rest  or  moved  ?  For  various  reasons 
perfect  rest  is  not  desirable :  first,  because  the  joint  would  become 
stiff,  often  in  a  very  unfavorable  position ;  secondly,  because  absolute 
rest  still  more  increases  the  atrophy  of  the  muscles.  Moderate  motion, 
both  passive  and  active,  avoiding  the  excitation  of  pain  or  fatigue, 
should  be  made ;  the  patient  may  make  the  passive  motions  with  his 
own  hands,  or  with  the  very  ingenious  machine  invented  by  JBonnet 
for  this  purpose.  Lastly,  we  must  add  something  about  muscular 
atrophy.  We  attempt  to  strengthen  the  muscles  by  friction,  elec- 
tricity, and  regulated  movements  both  active  and  passive  ;  here  cura- 
tive gymnastics  sometimes  prove  beneficial.  But,  to  be  of  benefit, 
any  of  these  methods  of  treatment  must  be  followed  perseveringly. 

From  this  therapeutical  review  you  see  we  are  not  poor  in  reme- 
dies that  may  prove  serviceable  in  chronic  rheumatism,  but  all  these 
modes  of  treatment  are  expensive  and  often  unattainable  by  pool 
patients,  and,  as  this  class  are  peculiarly  liable  to  the  disease,  thev 


CHRONIC   INFLAMMATION   OF  THE   JOINTS.  597 

are  very  unhappily  situated  in  regard  to  it.  Since  dry,  warm  air,  good 
nourishment,  protection  from  catching  cold,  and  baths,  are  seldom 
to  be  found  in  the  dwellings  of  the  poor,  and  since  these  are  a]> 
solute  necessities  for  the  treatment,  the  prescription  of  expensive 
medicines  is  a  pure  waste  of  money.  Still,  I  again  repeat,  the  sooner 
these  patients  come  under  treatment,  the  more  recent  the  disease,  the 
more  you  may  expect  from  treatment.  You  may  sometimes  arrest 
the  disease.  If  the  malady  be  already  far  advanced,  its  arrest  is  more 
difficult,  and  a  cure  is  rarely  to  be  expected.  I  believe  that  most 
cases  of  malum  coxas  senile  are  incurable  ;  still,  even  there  the  above 
remedies  form  the  rational  treatment.  Arthritis  deformans  monar- 
ticularis  is  incurable.  K  the  joint  be  much  deformed,  you  may  resect 
it  or  amputate  the  limb. 

[In  the  elbow-joint  the  abnormal  mobility  caused  by  smoothing 
off  of  the  bone  is  particularly  noticeable  ;  in  typical  cases  the  bones 
of  the  joint  may  readily  be  luxated  in  any  direction,  and  by  trac- 
tion on  the  forearm  may  be  separated  two  centimetres  ;  the  elbow 
forms  a  wabbling  joint,  in  the  strictest  sense,  on  which  the  muscles 
no  longer  have  any  effect ;  their  points  of  insertion  being  approxi- 
mated, the  muscles  prove  too  long  for  normal  function. 

Joint  affections  of  syphilitic  nature  occasionally  occur  under  the 
form  of  arthritis  deformans  ;  these  neither  belong  to  the  acute  pe- 
riod immediately  after  infection,  nor  to  the  results  of  development 
of  a  bony  gumma.  Their  existence  is  denied  by  some  surgeons,  in- 
correctly I  am  sure  from  my  own  experience.  For  I  have  occa- 
sionally seen,  in  children  with  hereditary  syphilis,  chronic  articular 
inflammations,  especially  of  the  knee-joint,  and  symmetrical,  chai-- 
acterized  by  moderate  collection  of  fluid  and  considerable  thicken- 
ing of  the  ends  of  the  bones,  particularly  of  the  condyles  of  the 
femur.  These  have  no  tendency  to  suppurate,  they  are  moderately 
painful,  the  increased  size  of  the  epiphyses  impedes  motion,  espe- 
cially perfect  extension  ;  that  these  processes  are  of  specific  na- 
ture is  shown  by  the  frequent  coincident  occurrence  of  iritis,  and 
by  the  striking  results  from  antisyphilitic  treatment,  especially  by 
iodide  of  potash,  without  local  applications  ;  thickening  of  the  ends 
of  the  bone  disappears  quickly.  I  know  of  no  post-mortem  ex- 
aminations of  such  cases.  Besides  these  there  are  cases  of  syphilitic 
disease  of  the  joints,  also  more  particularly  of  the  knee  where  tlic 
cartilage  is  destroyed  and  largely  replaced  by  hard,  filamentary, 
brawny  connective  tissue  ;  the  whole  synovia  is  thickened,  covered 
with  tufted  proliferations,  which,  however,  have  not  the  character 
of  fungous  granulations,  but  consist  of  firm  connective  tissue  and  fat ; 


598  CHRONIC   INFLAMMATION   OF  THE   JOINTS. 

tbe  bones  remain  unchanged.  The  clinical  symiotoms  are  scarcely 
distinguishable  from  those  of  arthritis  deformans  ;  moderate  pain 
and  impairment  of  motion  only  have  been  observed  ;  there  is  no 
suppuration  ;  the  disease  is  seen  in  young  persons  (twenty-five  to 
thirty  years),  and  accompanied  by  other  tertiary  affections.  This 
disease  differs  from  arthritis  deformans  by  the  absence  of  filamen- 
tation  and  proliferation  in  the  cartilage  and  the  smoothing  off  of 
the  articular  surfaces.] 


APPENDIX  I. 

LOOSE  BODIES  m  THE  JOE^TS  (MTIRES  ARTICULAKES). 

By  these  loose  bodies  in  the  joints,  we  mean  more  or  less  firm 
bodies,  forming  in  a  joint.  We  exclude  foreign  bodies  entering  the 
joint  from  without,  such  as  needles,  bullets,  etc.,  or  detached  pieces 
of  bone,  lying  loose  in  the  joint.  There  are  two  varieties  of  loose 
bodies  :  1.  Small,  oval  bodies,  resembling  melon-seeds  or  irregular  in 
shape,  which  usually  form  in  large  numbers,  and  on  microscopical  ex- 
amination are  found  to  consist  of  fibrine.  These  form  in  joints  with 
chronic  dropsy,  and  are  deposits  from  the  qualitatively  and  quantita- 
tively abnormal  synovia,  just  as  the  analogous  bodies  are  in  dropsy 
of  the  sheath  of  the  tendons ;  blood-clots  may  also  possibly  serve  as 
a  source  of  origin  of  such  bodies.  This  form  of  loose  bodies  never 
requires  any  operation  ;  it  is  simply  an  accidental  accompaniment  of 
hydrops  articulorum  chronicus.  Occasionally  we  may  predict  their 
presence  from  finding  soft  friction  when  palpating  the  joint ;  this  does 
not  change  the  treatment  of  chronic  articular  dropsy,  and  only  com- 
plicates it  in  that  it  renders  more  difficult  the  eventual  reduction  of 
the  joint  to  its  normal  size. 

2.  The  other  variety  of  articular  bodies  is  of  cartilaginous  firm- 
ness, generally  containing  bone-nuclei,  sometimes  adherent,  at  others 
quite  loose  in  the  joint.  The  form  is  quite  varied,  being  sometimes 
very  odd.  The  name  "  joint  mouse  "  (Gelenkmaus)  may  have  arisen 
from  some  accidental  shape,  resembling  a  mouse.  [These  loose 
bodies  are  usually  about  the  size  of  a  small  bean  or  an  almond  ;  in 
the  Vienna  Museum  is  one  about  as  large  as  the  calcaneus,  which 
is  attached  by  a  pedicle  to  the  capsule  of  the  knee-joint.  One 
we  found  in  the  knee  of  an  old  woman  was  almost  as  large  as  the 
patella,  and  caused  but  little  suffering.]  These  bodies  are  always 
rounded,  but  seldom  regularly  oval  or  round,  being  usually  nodular 
or  warty  ;  their  shape  is  that  of  the  osteophytes  in  arthritis  defor- 


LOOSE  BODIES  IN   THE   JOINTS. 


699 


mans.  Microscopically  they  consist  of  a  thin  covering  of  true  filamen- 
tary or  hyaline  cartilage,  which,  from  the  centre,  ossifies,  or  sometimes 
only  calcifies.  As  these  cartilages  are  mostly  organized,  they  cannot 
be  regarded  as  deposits  from  the  synovia ;  but,  even  if  found  quite 
free,  they  must  formerly  have 

been  connected  with  and  have  Fiq.  io3. 

formed  in  living  tissue,  and  sub- 
sequently become  detached. 
The  actual  process  is  as  fol- 
lows :  These  bodies  are  mostly 
osteophytes,  which  have  en- 
tered the  joint  from  without ; 
rarely  they  form  in  the  apices 
of  the  synovial  tufts.  Even 
normally  there  are  sometimes 
cartilage-cells  in  the  tufts ; 
these  may  proliferate,  and 
thus  in  the  tuft  we  should 
have  a  cartilage-nucleus,  a 
cartilage-tumor,  an  enchon- 
droma,  which  subsequently  os- 
sifies from  the  centre.  For  a 
time  this  tumor  remains  at- 
tached to  the  tuft,  but  finally 
it  breaks  off  and  then  lies 
loose  in  the  joint.  But  by  far 
the  most  frequent  form  of  these 
articular  bodies  is  from  the  for- 
mation of  ossifying  cartilages 
(osteophytes)  in  the  capsule 
of  the  joint  immediately  un- 
der the   synovial    membrane, 

which  may  enter  the  joint  and  finally  tear  loose  and  become  free.  It 
is  probable  that,when  once  detached  and  lying  free  in  the  joint,  these 
bodies  do  not  grow  any  more  ;  although  it  is  not  impossible  that  the}'^ 
might  derive  their  nutriment  from  the  synovia.  The  development  of 
loose  bodies  is  always  accompanied  by  some  dropsy  of  the  joint ;  per- 
haps the  latter  is  occasionally  the  primary  disease.  Loose  bodies 
occur  almost  exclusively  in  the  knee-joint,  and  only  in  adult  patients ; 
they  are  very  rare,  perhaps  the  rarest  of  articular  diseases.  There  la 
an  undoubted  connection  between  the  formation  of  articular  carti- 
lages, arthritis  deformans,  and  hydrarthrus.  These  diseases  are  of  the 
same  class,  and  from  a  possibly  congenital  or  developed  general  diath 


Multiple  articular  bodies,  after  CruvetlMcr. 


600  CHRONIC   INFLAMMATION   OF   THE   JOINTS. 

esis  they  form  a  contrast  to  the  fungous  and  fungous-sappurative 
articular  inflammations. 

The  symptoms  which  may  be  considered  as  characteristic  of  the 
existence  of  free  bodies  in  the  joint  are  as  follows  :  The  patient  has 
lono-  had  moderate  dropsy  of  the  knee-joint,  and,  while  walking,  sud- 
denly has  a  severe  pain,  which  prevents  his  walking  for  the  time  be- 
ino- ;  the  knee  stands  between  flexion  and  extension,  and  cannot  be 
moved  till  it  has  been  rubbed  in  a  certain  way.  This  symptom  is  due 
to  the  loose  body  being  caught  between  the  bones  forming  the  joint, 
between  the  semilunar  cartilages,  or  in  one  of  the  synovial  sacs.  But, 
even  before  this,  these  patients  usually  complain  for  weeks  or  months 
of  weakness  or  slight  pain  in  the  knee,  and,  as  already  stated,  exami- 
nation will  generally  show  a  slight  amount  of  dropsy  there.  From 
the  peculiar  mode  of  occurrence  and  subsidence  of  the  pain,  the  pa- 
tients themselves  often  suspect  that  there  is  a  movable  body  in  their 
knee-joint ;  not  unfrequently  they  can  feel  it  distinctly,  and  can,  by 
certain  motions  of  the  joint,  render  it  perceptible  to  the  surgeon.  In 
other  cases  the  surgeon  does  not  feel  the  body  till  after  several  ex- 
aminations, and  can  move  it  around  in  various  directions ;  it  often 
disappears  again,  and  it  may  be  several  days  or  weeks  before  it  again 
coilies  in  a  position  where  it  can  be  felt.  These  symptoms  only  be- 
come very  evident  when  the  body  is  detached.  While  still  adherent, 
or,  if  too  large  to  be  caught  as  above  mentioned,  it  causes  little  or  no 
difficulty. 

Hence,  although  the  inconveniences  of  a  loose  body  and  of  a  mod- 
erate dropsy  of  the  knee-joint  are  not  always  great,  and  do  not 
increase  spontaneously,  or  go  on  to  suppurative  inflammation,  and 
only  have  occasional  subacute  inflammation,  with  serous  eff'usion  after 
some  exciting  cause,  still,  in  other  cases,  the  pain  from  the  squeezing, 
and  the  anxiety  about  being  constantly  liable  to  it,  are  so  great  that 
many  patients  imperatively  demand  aid. 

The  attempt  to  fix  these  bodies  by  adhesive  inflammation,  induced 
either  by  a  compressive  bandage,  tincture  of  iodine,  or  blisters,  has 
had  little  success.  The  operation  consists  in  the  extraction  of  the 
foreign  body ;  it  is  done  as  follows  :  The  loose  body  is  pressed  tightly 
under  the  skin,  at  one  side  of  the  joint;  the  skin  over  it  is  then 
pressed  strongly  upward,  and  put  still  more  on  the  stretch ;  then  cut 
through  the  skin  and  capsule  down  on  to  the  body,  and  let  the  latter 
spring  out,  or  lift  it  out  with  an  elevator  (perhaps  an  ear-spoon,  aa 
Fock  has  done) ;  instantly  close  the  wound  with  the  finger,  extend 
the  leg,  let  the  skin  return  to  its  normal  position,  so  that  the  cut  in 
it  lies  lower  than  in  the  capsule,  and  the  two  wounds  do  not  commu- 
nicate directly ;  the  skin-wound  is  now  to  be  closed  with  sutures  and 


ANCHYLOSIS.  601 

plasters,  and  the  limb  extended  on  a  splint ;  a  plaster-splint  would  be 
very  suitable  here  ;  one  niight  be  made  with  a  large  opening-  and 
applied  even  before  the  operation.  According  to  the  symptoms  of 
inflammation  that  arise,  the  treatment  for  traumatic  inflammations  of 
the  joint  is  to  be  instituted.  In  former  times  these  operations  were 
very  unfortunate  ;  they  were  not  unfrequently  followed  by  severe 
inflammations  of  the  joint,  and  occasionally  the  surgeon  had  to  con- 
gratulate himself  if  he  saved  the  patient's  life  by  amputating  at  the 
thigh.  The  modes  of  operation  were  often  changed  ;  finally  that 
above  described,  which  is  the  simplest,  carried  the  day.  Fock  per- 
formed this  operation  five  times,  always  with  success.  The  symptoms 
of  inflammation  were  insignificant,  and  the  patients  could  usually 
return  to  their  occupations  in  a  few  weeks.  As  in  the  extraction  of 
cataract  or  vesical  calculus,  much  depends  on  the  operation  being 
well  performed  and  without  much  bleeding  or  other  hinderance.  If  a 
loose  body  causes  no  inconvenience,  we  may  apply  a  knee-cap  to 
limit  the  dropsy  and  give  the  joint  a  certain  amount  of  firmness,  so 
that  there  shall  not  be  too  much  motion  ;  this  often  gives  the  patient 
great  rest. 

APPENDIX  II. 

NEUEOSES  OF  THE  JOINTS. 

By  neuroses  and  neuralgias  we  mean  diseases  characterized  by 
typical  or  irregular  pains  whose  causes  we  cannot  find  in  any  change 
of  tissue.  We  assume  that  there  is  a  functional  disturbance  in 
the  nerves  without  morphological  changes.  There  is  no  doubt  that 
there  are  purely  functional  disturbances,  which  we  call  weakness 
and  irritation,  in  the  tissues,  and  especially  in  the  nerves,  where  for 
our  senses,  even  with  all  modern  aids,  no  morphological  or  chemi- 
cal changes  are  discoverable,  either  during  life  or  after  death.  We 
cannot  say  if  such  changes  do  nevertheless  exist  ;  what  we  cannot 
perceive  with  our  senses  does  not  exist  for  us.  So  that  state  of  the 
joint  where  there  is  pain  for  which  we  can  find  no  physical  cause  is 
called  a  "neurosis  of  the  joint."  The  pains  are  never  typical,  i.  e., 
occurring  at  certain  hours  of  the  day  in  paroxysms,  as  in  neuralgia 
of  the  trigeminus,  for  example.  Brodie  first  classed  neuroses  of  the 
joints  as  special  diseases.  Esmarch,  Stro'tneyer,  and  Wernher  have 
of  late  paid  special  attention  to  these  aflfections  ;  according  to  them, 
the  group  should  also  include  those  cases,  with  slight  but  still  per- 
ceptible anatomical  changes,  where  pain  and  functional  disturbance 
are  the  chief  symptoms,  and  tlieir  severity  is  out  of  proportion  to  the 
apparent  causes  of  disease.     This  would  place  neuroses  of  the  joints 


6Q2  CHRONIC   INFLAMMATION   OF   THE   JOINTS. 

among  hypersesthesias  with  their  reflex  complications  ;  in  short, 
would  class  them  with  hysteria  and  hypochondria.  The  cases  that  I 
have  seen,  which  from  the  descriptions  of  authors  were  to  be  placed 
in  this  class,  I  formerly  regarded  as  slight  diseases  of  the  joints, 
whose  symptoms  were  exaggerated  in,  or  even  simulated  by,  hyster- 
ical women  and  girls,  or  sometimes  as  commencing  and  not  yet  well- 
defined  diseases  of  joints  or  bones  ;  and  lastly,  sometimes  as  great 
sensitiveness  remaining  after  the  disease  had  run  its  course.  It  is 
well  to  have  a  name  for  this  group  of  cases,  but  they  are  not  all  to 
be  viewed  from  the  same  point  or  treated  in  the  same  way.  Gen- 
eral medical  experience  and  knowledge  of  human  nature  must  aid 
most  in  the  treatment  of  hysterical  patients ;  the  peculiarities  and 
persistence  of  women  in  carrying  out  simulated  contractions  and 
spasms  is  incredible  to  any  one  but  an  experienced  physician.  Hys- 
teria is  really  a  mental  disease,  often  incurable,  or  only  temporarily 
curable.  For  lessening  the  sensitiveness  of  joints  we  may  try  cold 
douches,  baths,  sea-baths,  or  active  use  of  the  joint  ;  the  last  is 
especially  advised  by  Esrnarch.  Still,  in  just  such  neuroses,  which 
had  remained  after  disease  of  the  joints,  I  have  seen  beneficial  ef- 
fects from  thermal  mud-baths  and  electrical  treatment.  Benefit  may 
also  be  expected  from  massage. 


LECTURE    XLI. 

Ancliyloses:  Varieties,  Anatomy,  Diagnosis,  Treatment;  Gradual  Forced  Extension  ; 
Operations  with  the  Knife. 

YoTJ  know  that  by  anchylosis  we  mean  a  stiff  joint,  but  I  must  add 
that  this  designation  is  used  only  when  the  process  which  causes  the 
stiffness  of  the  joint  has  ceased  ;  that  is,  when  the  limitation  or  total 
loss  of  mobility  of  the  joint  is  the  only  morbid  symptom  present.  For 
instance,  if  during  an  inflammation  of  the  knee  or  hip  the  limb  be 
strongly  flexed  by  involuntary  continuous  contraction  of  the  muscles, 
and  the  joint  cannot  be  extended  on  account  of  the  pain,  although 
it  should  be  mechanically  possible,  we  do  not  call  it  anchylosis  of 
the  joint,  but  articular  inflammation  with  contraction  of  the  muscles. 

The  causes  why  a  joint  cannot  be  extended  after  the  subsidence 
of  the  acute  inflammation  are  partly  mechanical  hinderances  either  in 
the  joint  or  exterior  to  it,  or  in  parts  actually  belonging  to  the  joint. 
A  muscle  shortened  by  atrophy  and  shrinking,  a  strongly -contracted 
cicatrix  of  the  skin,  especially  when  on  the  flexor  side  of  the  limb, 
may  greatly  impair  the  normal  mobility  of  the  joint ;  such  cases  are 
not  meant  when  we  speak  briefly  of  anchylosis;  they  are  termed  mus- 
cular or  cicatricial  contraction.     Should  we  term  these  varieties  of 


ANCHYLOSES. 


603 


[imitation  of  motion  anchyloses,  it  is  well  to  distinguish  them  as 
anchyloses  from  external  causes,  anchylosis  spuria,  etc.  Now,  we  have 
left  those  cases  of  stiffness  of  the  joints  which  are  caused  by  patli- 
ological  changes  of  parts  actually  pertaining  to  the  joint ;  under  this 
head  we  have  the  following  cases : 

1.  Cicatricial  adhesions  between  adjacent  surfaces  of  the  joint 
itself;  these  may  differ  greatly  in  variety  and  extent;  they  form  after 
cure  of  fungous  articular  inflammations,  by  adhesion  of  the  prolifer- 
ating-granulating  surfaces  ;  stringlike  adhesions  are  thus  formed,  like 
those  between  the  costal  and  pulmonary  pleura,  or  else  there  are 
thick  extensive  adhesions  of  the  surfaces ;  along  with  this  state  the 
cartilage  may  be  partly  preserved,  or  it,  together  with  part  of  the  bone, 
may  be  destroyed.  Generally,  these  adhesions,  like  other  cicatrices, 
are  formed  of  connective  tissue ;  in  other  cases,  especially  when  the 
joint  remains  perfectly  quiet,  this  cicatricial  tissue  ossifies,  and  the 
two  articular  surfaces  are  united  by  bony  bridges,  or  else  the  entire 
surfaces  are  completely  soldered  together  (Figs.  104-106). 

Fie.  104. 


Band-like  adhesions  in  a  resected  elbow-joint  from  an  adult,  almost  natural  size. 


2.  Further  impediments  to  mobility  are  cicatricial  shrinkages  of 
the  articular  capsule,  of  the  accessory  ligaments,  and  even  of  the 
semilunar  cartilages,  which  may  also  be  entirely  destroyed.  These 
cicatricial  contractions  occur  not  only  at  places  where  fistulas  have 
formed,  but  also  when  there  has  been  no  suppuration,  for  any  tissue 
that  has  long  been  infiltrated,  and  so  more  or  less  softened,  subse- 
quently shrinks  some,  after  the  process  has  run  its  course. 

3.  A  not  insignificant  impediment  to  mobility,  and  one  which  is 
the  cause  of  its  occasional  non-recurrence  after  extensive  fungous 
inflammations  of  the  joints,  lies  in  the  adhesion  of  the  walls  of  the 
synovial  sacs  about  the  joint,  which  normally  should  glide  over  each 
other.  To  render  this  clear  to  you,  I  must  touch  on  the  normal  con- 
ditions of  the  larger  joints  in  motion.     The  capsule  of  the  joint  is 


604 


CHRONIC  INFLAMMATION  OF  THE  JOINTS. 


Complete  cicatricial  adhesion  of  the  articular  sur- 
faces of  the  elbow-joint  of  a  child,  the  trochlea 
of  the  humeras  and  part  of  the  olecranon  de- 
stroyed ;  section  lengthwise,  natural  size. 


never  so  elastic  as  to  adapt  itself  by  this  means  alone  to  all  positiono 
of  the  joint.  If  you  imagine  a  humerus  lying  on  the  thorax,  then  at 
the  lower  part  of  the  joint  the 
capsule  would  have  to  be 
firmly  drawn  together,  above 
it  would  have  to  be  greatly 
stretched ;  if  you  imagine  the 
arm  raised  as  high  as  possible, 
the  upper  part  of  the  capsule 
would  have  to  be  strongly 
drawn  together,  and  the  lower 
stretched ;  the  articular  cap- 
sule would  have  to  be  as  elas- 
tic as  rubber ;  this  is  not  the 
case :  on  changing  the  extreme 
positions  of  the  joint,  it  con- 
tracts little  or  not  at  all ;  it 
folds  up  in  certain  directions ; 
if  the  position  of  the  joint 
changes,  the  fold  smooths  out, 
and  on  the  opposite  side  which 
was  previously  smooth  another 
fold  forms  in  the  capsule.  You 
here  see  perpendicular  sections 
of  the  shoulder-joint,  parallel 
to  the  anterior  surface  of  the 
body  (seen  from  the  front,  af- 
ter Hey^le)  in  an  elevated  posi- 
tion (Fig.  I07),hanging  by  the 
side  (Fig.  108). 

If  the  synovial  membrane 
become  diseased,  the  joint  usu- 
ally remains  in  a  certain  posi- 
tion, the  humerus  is  generally 
depressed,  the  lower  part  of 
the  synovial  sac  (Fig.  108,  «) 
may  suppurate,  shrink,  and 
become  adherent ;  then,  even 
if  the  joint  were  otherwise 
healthy,  it  would  be  impossi- 
ble to  raise  the  arm,  because 
the  capsule  at  the  lower  part 
of  the  joint  could  not   unfold, 


Elbow-joint  anchylosed  by  bony  bridjres,  rcsoctud 
from  an  adult ;  about  natural  size. 

Anchyloses   may  thus   result    wbily 


ANCHYLOSES. 


605 


the  cartilage  remains  intact;  the  secretion  of  synovia  ceases,  in 
the  course  of  years  the  cartilage  may  degenerate  into  connective  tis- 
sue (as  in  old,  immovable  luxations),  or  may  even  ossify,  and  the 
anchylosis  will  thus  become  more  immovable.  Similar  circumstances 
exist  in  almost  all  the  joints;  you  will  find  the  best  representations 


Fia.  107. 


Fig.  lOS. 


SECTION  OF  TIEE  SHOUXDER-JOINT,   SEEN  FROM  THE  FRONT. 

Fig.  95,  the  capsule  folded  above,  at  a.  Fig.  96,  the  capsule  folded  below,  at  a. 

of  these  in  Senle's  anatomy.  H.  Vblkmann  had  previously  described 
this  variety  of  anchylosis,  which  occurs  especially  often  in  young 
persons  after  subacute  coxitis  without  suppuration,  but  with  great 
tension  of  the  muscles,  as  "  cartilaginous  anchylosis."  The  name  is 
well  chosen,  in  so  far  as  in  them  the  cartilage  long  remains  intact. 

4.  A  further  mechanical  obstruction  may  lie  in  the  bony  deposits 
which  form  in  the  joint  on  the  articular  surfaces  of  the  bones  impli- 
cated ;  for  instance,  if  the  fossa  sigmoidea,  anterior  or  posterior  of  the 
lower  end  of  the  humerus,  fill  up  with  newly-formed  bone,  neither  the 
processus  corouoideus  nor  anconeus  of  the  ulna  can  enter  it,  and  in  the 
former  case  the  arm  cannot  be  fully  flexed,  in  the  latter  it  cannot  be 
fully  extended.  This  hinderance  is  most  common  in  arthritis  de- 
formans ;  it  is  rare  in  fungous  inflammations  of  the  joint  (Fig.  101). 

5.  Lastly,  as  a  result  of  caries  of  the  ends  of  the  bones,  there  may 
be  such  loss  of  substance  that  the  epiphyses  wUl  stand  obliquely  to 
each  other  and  cannot  be  brought  into  position  again,  because  their 
surfaces  are  too  much  changed,  and  do  not  fit  on  each  other  in  the 
abnormal  position  (pathological  luxation),  or  cannot  be  moved  at  all. 
Examine  Fig.  105  again ;  as  a  sequence  of  the  destruction  of  t!ie 
trochlea  humeri,  the  ulna  is  so  drawn  toward  the  humerus  that,  even 
tf  some  motion  were  possible,  complete  flexion  could  not  take  place, 
because  the  processus  coronoideus  strikes  on  the  humerus  anteriorly, 
as  the  fossa  sigmoidea  is  absent.     In  caries  of  the  knee  also  the  tibia 


606  CHRONIC  INFLAMMATION  OF  THE  JOINTS. 

may  be  half  dislocated  outwardly  and  posteriorly,  so  that  the  sui  faces 
which  belong  together  no  longer  lie  in  apposition,  and  in  the  abnormal 
position  there  is  no  motion  at  all,  or  only  a  slight  amount. 

Besides  these  causes  of  immobility  which  lie  more  or  less  in  the 
joiat,  there  may  be  external  ones,  especially  the  above-mentioned 
muscular  contractions,  as  well  as  cicatrices  which  may  become  adherent 
to  tlie  muscles,  tendons,  or  bones,  and  thus  materially  aid  in  fixing 
the  joint  in  a  false  position. 

Generally,  the  diagnosis  of  anchjlosis  is  not  difficult ;  but  it  may 
not  be  easy  to  decide  which  of  the  above-mentioned  factors  should  be 
blamed  for  the  deficiency  or  entire  absence  of  motion.  When  the 
stifihess  is  complete,  we  readily  suppose  that  there  is  bony  anchylosis, 
but  this  is  not  ahvays  the  case ;  very  short,  strong  adhesions,  espe- 
cially if  very  broad,  must  also  cause  absolute  immobility.  The  longer 
such  an  anchylosis  remains  entirely  immovable,  the  greater  the  prob- 
ability that  there  is  bony  anchylosis ;  even  when  the  joint  is  propor- 
tionately little  diseased,  and  the  greater  part  of  the  articular  cartilage 
is  normal,  if  the  joint  has  remained  at  rest  many  years  (perhaps  only 
as  a  result  of  shrinkage  of  the  capsule),  complete  bony  anchylosis  will 
often  form  gradually ;  for  even  a  healthy  joint  will  finally  become 
anchylosed  if  kept  immovable  for  years ;  motion  is  an  absolute  ne- 
cessity for  the  continued  health  of  the  synovial  membrane  and  carti- 
lage ;  you  may  even  conclude  this  to  be  the  case  from  the  fact  that  all 
the  articulations  which  are  subject  to  little  or  no  motion  (as  the  inter- 
vertebral, pelvic,  and  sternal),  have  a  very  slightly-developed  synovial 
membrane,  and  are  very  deficient  in  cartilage.  When  the  motion  of 
the  joint  ceases,  the  secretion  of  a  useful  synovia  is  arrested,  the  sy- 
no\-ial  membrane  becomes  dry,  tough,  the  cartilage  becomes  filamen- 
tary, and  the  entire  beautiful  apparatus  finally  changes  to  a  cicatricial 
connective  tissue  which  may  ossify ;  then  the  function  of  the  joint 
ceases.  We  have  made  these  statements  for  the  purpose  of  calling 
attention  to  the  possibiHty  of  deciding,  from  the  duration  of  an  im- 
movable anchylosis,  about  its  firmness.  But  if  the  anchylosis  be  mov- 
able, even  if  very  slightly,  the  s}T)ovial  membrane  is  rarely  destroyed ; 
part  of  the  cartilage  also  is  usually  preserved  in  such  cases.  We  may 
be  greatly  deceived  as  to  the  mobility  or  immobility  of  anchylosis,  if 
we  leave  out  of  consideration  the  tension  of  the  muscles  ;  frequently, 
we  do  not  fully  comprehend  the  amount  of  this  mechanical  hinderance, 
till  we  arrest  the  muscular  contractility  by  anaesthesia,  which  must 
be  pushed  to  the  point  of  total  relaxation  of  the  muscles. 

Now,  what  is  to  be  done  for  these  anchyloses  ?  Can  we  render  the 
stiff  joint  movable  again  ?  In  most  cases  this  question  can  be  an- 
BU'crefl  affirmatively.    Can  we  permanently  preserve  this  mobilitv  <<nd 


EXTENSION  OF  ANCHYLOSES.  607 

restore  the  normal  function  even  approximately  ?  Unfortunately,  this 
is  rarely  possible.  "What  shall  then  be  done  ?  What,  then,  is  the  use 
of  treatment  ?  This  latter  question  is  sometimes  a  just  one,  but  is 
not  usually  so.  We  have  already  said  that,  in  inflammations  of  the 
joints,  the  limbs  usually  assume  an  abnormal  position,  a  position  in 
which  they  are  very  unserviceable  ;  a  leg  bent  at  right  angles  at  the 
knee  is  a  useless,  unnecessary  burden,  hence  such  limbs  were  formerly 
amputated,  as  the  patient  could  go  about  better  with  a  good  wooden 
leg  than  with  two  crutches.  An  arm  entirely  extended  at  the  elbow, 
or  only  slightly  flexed,  is  also  a  very  inconvenient  member,  and  very 
unsuitable  for  seizing  and  holding  objects,  etc.  By  simply  bringing 
the  anchylosed  limb  into  a  position  where  it  is  relatively  most  useful, 
as  the  knee  into  the  extended  position,  the  arm  to  a  right  angle,  we 
may  do  the  patient  much  good ;  hence,  these  operations  of  straight- 
ening or  bending  anchyloses  are  very  satisfactory.  Anchyloses  in  an 
inconvenient  position  were  very  frequent  for  a  time ;  they  are  becoming 
rarer,  and  will  disappear  entirely  as  soon  as  universal  attention  is  paid 
to  the  principle  we  urge  of  placing  the  joint  in  the  best  position  for 
anchylosis,  when  we  are  treating  acute  or  chronic  inflammations.  No 
surgeon  of  modern  times  will  have  occasion  to  operate  on  anchylosis 
for  the  improvement  of  position,  in  a  patient  that  he  himself  treated 
for  inflammation  of  the  joint.  But  there  are  still  many  cases  that 
have  to  be  treated  in  the  country  under  most  unfavorable  circumstances, 
where  angular  anchylosis  of  the  knee  or  hip  results,  so  that  extension 
of  anchylosis  is  stiU  among  the  tolerably  frequent  operations. 

Attempts  to  straighten  deformed  and  stiff  limbs  are  quite  old. 
Even  in  the  surgical  writings  of  physicians  of  the  middle  ages  we  find 
illustrations  and  descriptions  of  machines  constructed  for  this  pur- 
pose, for  the  method  of  relieving  the  deformities  by  slow  extension 
with  machinery  is  the  older.  A  large  number  of  apparatus  for  the 
various  joints  have  been  constructed,  by  whose  aid  the  extension  and 
flexion  of  the  extremities  may  be  induced  by  the  action  of  a  screw. 
Now  these  instruments  are  chiefly  employed  in  cases  where  it  is 
thought  that,  while  straightening  the  joint,  we  may  retain  its  mo- 
bility ;  but  as  these  cases  are  very  rare,  and  as  they  also  may  be  really 
improved  by  rapid  extension,  these  machines  are  much  less  used.  In 
contradistinction  to  slow  extension  of  anchyloses,  we  have  the  rapid, 
forcible  extension,  which  is  falsely  termed  hrisement  force.  Before 
chloroform  was  known  and  employed  in  these  cases,  this  operation 
was,  on  many  accounts,  objectionable.  It  was  very  painful,  and  not 
free  from  danger ;  it  required  a  great  deal  of  power  in  the  forcible  ex- 
tension of  anchylosis  for  breaking  and  tearing  them  up  ;  this  was  due 
not  only  to  the  obstructions  in  the  joint,  but  also  very  greatly  to  the 


g08  CHRONIC   INFLAMMATION   OF   THE   JOINTS. 

muscles,  wliich  contracted  strongly  as  soon  as  the  pain  began.  Hence, 
before  trying  to  extend  the  anchyloses,  it  was  often  necessary  to  di- 
vide the  tendons  of  the  tense  muscles ;  this  complicated  the  operation. 
Moreover,  the  after-treatment  was  not  correctly  understood :  the  ex 
tended  limb  was  bound  to  a  splint,  or  held  firmly  by  machinery ;  the 
consequences  were  severe  inflammation  and  great  swelKng;  the 
method  did  not  become  popular.  Houmer  and  Dieffenbach  were  al- 
most the  only  ones  who  occasionally  resorted  to  it;  other  surgeons 
preferred  to  consider  these  patients  as  incurable,  or  to  send  them  to 
orthopedists  for  gradual  extension,  or,  if  the  patients  were  poor,  to 
amputate  the  limb,  so  that  they  might  have  a  wooden  leg  to  go  about 
on  more  securely.  So  the  matter  stood  till  B.  von  Langenheck  in  184G 
made  the  first  attempt  to  extend  an  anchylosed  knee-joint  while  the 
patient  was  anECsthetized.  This  showed  the  interesting  fact  that  under 
anaesthesia  the  contracted  muscles  become  perfectly  relaxed  and  pli- 
able, and  may  be  stretched  like  india-rubber ;  this  rendered  tenotomy 
and  myotomy  unnecessary  in  this  operation.  As  anaesthesia  rendered 
the  operation  painless,  it  could  be  done  more  slowly  and  carefully, 
and  with  the  aid  of  the  hands  alone.  The  results  were  so  very  favor- 
able that  this  method,  which  in  its  new  form  scarcely  deserved  any 
longer  the  rather  brutal  name  of  "  brisement  forc6,"  soon  became  uni- 
versal, and  now  it  has,  perhaps,  too  much  displaced  extension  by  in- 
struments and  weights.  The  method  of  the  operation,  the  indications, 
the  precautions  to  be  observed,  and  the  after-treatment,  were  gradually 
so  perfected  by  B.  von  Langenheck  that  this  operation  may  be  re- 
garded as  one  of  the  safest  and  simplest  in  surgery.  To  prevent 
yom*  being  misled  by  the  name  "  brisement  forc6,"  and  forming  too 
horrible  an  idea  of  the  operation,  I  will  describe  for  you  the  exten- 
sion of  a  knee  bent  at  right  angles.  At  first  the  patient  lies  on  his 
back,  and  is  gradually  anaesthetized  so  deeply  that  all  the  muscles  are 
relaxed,  and  no  reflex  movements  occur.  When  this  state  has  been 
reached,  the  patient  is  turned  on  his  belly ;  one  assistant  holds  the 
head,  another  places  his  arm  under  the  breast  of  the  patient  to  facili- 
tate respiration ;  the  pulse  and  breathing  are  carefully  watched,  for 
the  operation  must  be  interrupted  at  once  if  dangerous  symptoms  fol- 
low the  deep  anaesthesia.  The  patient,  lying  on  his  face,  is  to  be 
drawn  toward  the  lower  end  of  the  operating-table  till  the  knee 
comes  to  the  edge  of  the  table,  which  should  be  covered  by  a  firmly- 
stuffed  horse-hair  cushion.  Now  an  assistant  with  both  hands  presses 
as  strongly  as  possible  on  the  thigh ;  the  operator  stands  at  the  outer 
Bide  of  the  left  (anchylosed)  knee,  places  his  left  hand  in  the  pophteal 
space,  so  as  to  depress  the  thigh,  and  the  right  on  the  posterior 
surface  of  the  leg,  corresponding  to  the  posterior  surface  of  the  con- 


EXTENSION  OF  ANCHYLOSES.  609 

dyles  of  tlie  tibia,  that  is,  close  above  the  calf,  and  with  his  right 
hand  he  makes  downward  pressure  on  the  leg.  If  the  anchylosis  be 
still  recent,  and  not  too  firm,  the  leg  will  gradually  give  way  with  a 
perceptible  soft  crackling  and  tearing,  and  will  be  straightened  by 
degrees.  Should  extension  not  be  made  so  readily,  the  operator 
places  his  hand  lower  on  the  leg,  about  the  calf  or  close  below  it ; 
but  then  he  should  not  use  so  much  force  as  he  could  above,  because 
he  might  readily  fracture  the  tibia  just  below  tlie  condyles,  especially 
if  the  bones  were  a  little  soft ;  the  force  should  here  act  more  in  the 
way  of  traction  or  extension.  If  we  do  not  succeed  even  by  this  last 
means,  we  should  attempt  to  rupture  the  adhesions  by  strong  flexion ; 
we  seize  the  leg  from  the  front  and  try  to  flex  it  by  slow,  regular  press- 
ure ;  by  this  means  the  adhesions  sometimes  rupture  more  readily 
than  by  movements  toward  extension ;  after  a  few  of  the  adhesions 
have  been  torn,  extension  is  generally  easy.  All  painful  twisting 
and  wrenching  is  decidedly  injm-ious,  and  very  rarely  does  any  good. 
When  we  have  made  as  much  extension  as  we  consider  prudent  for 
one  operation,  or,  if  the  leg  be  fully  extended,  we  turn  the  patient  on 
the  back  again,  let  the  assistants  press  down  the  thigh  by  means  of 
Sueter's  bandages,  extend  the  leg  by  the  foot,  and  from  the  foot  to 
within  an  inch  of  the  perinseum  apply  a  stout  plaster-of-Paris  dressing, 
inserting  thick  layers  of  wadding  at  the  knee  and  at  the  ends  of  the 
bandage  (below  and  above,  where  there  is  most  pressure).  But,  as 
the  plaster  does  not  always  harden  before  the  patient  recovers  from 
his  anc^sthesia,  we  bind  a  well-padded  hollow  splint  to  the  flexor  side 
of  the  limb,  to  prevent  the  knee  contracting  again  ;  this  hollow  splint 
is  to  be  removed  after  three  or  four  hours ;  by  that  time  the  plaster- 
dressing  is  hard  enough  to  resist  the  contracting  muscles.  The  pain 
that  the  patient  suffers  after  recovering  from  his  angesthesia  is  not  al- 
ways severe,  often  it  is  remarkably  slight  in  proportion  to  the  force 
emploj^ed.  The  foot  sometimes  becomes  oedematous,  if  it  has  not 
been  properly  bandaged ;  but  if  this  has  been  done,  or  is  done  im- 
mediately after  the  operation,  there  is  no  further  trouble.  Should  the 
pain  be  very  severe  directly  after  the  operation,  we  may  appl}'  a  blad- 
der of  ice  over  the  plaster-bandage,  and  give  a  quarter  of  a  grain  of 
morphia.  After  eight  or  ten  days  we  may  allow  the  patient  to  grat- 
ify his  wish  of  getting  up  with  the  bandage  on,  and  going  about  on 
crutches,  or  with  sticks.  After  eight  or  twelve  weeks  the  anchylosis 
has  healed  in  its  new  position.  Meanwhile,  the  patient  has  thrown 
aside  his  crutches,  and  goes  about  with  a  stick,  perhaps  even  with- 
out any  support,  his  knee  being  stiff,  but  straight ;  then  the  bandage 
may  be  removed,  and  the  patient  regarded  as  cured. 

In  the  above  case  we  have  supposed  that  an  operation  succeeded 
40 


610  CHRONIC   INFLAMMATION   OF   THE   JOINTS. 

in  straightening  the  knee.  But  tins  is  not  always  the  case  ;  fre- 
quently at  the  first  operation  we  dare  not  go  so  far  without  risking 
serious  consequences.  What  circumstances  can  prevent  our  complet- 
ing the  operation  at  one  sitting  ?  These  are  chiefly  extensive  cica- 
trices of  the  skin,  which  demand  very  great  precautions  ;  cicatrices  in 
the  hollow  of  the  knee  are  especially  difficult  to  deal  with,  and  must 
be  extended  gradually ;  they  would  be  torn  if  we  tried  to  force  the 
extension.  Occasionally,  also,  the  cicatrices  surround  large  vessels 
and  nerves,  whose  sheaths  may  have  participated  in  the  previous  ul- 
ceration, and  tearing  these  parts  would  be  a  very  serious,  perhaps 
fatal  complication.  Breaking  up  of  any  cicatrix  may  be  followed  by 
suppuration,  or  even  mortification ;  hence  we  should  never  stretch 
cicatrices  of  the  skin  to  the  extreme  point  to  rupture  them.  Hav- 
ing reached  the  point  where  the  cicatrices  are  very  tense,  Ave  should 
stop,  api^ly  the  dressing,  and  repeat  the  operation  in  four  to  six 
weeks,  and  so  on  till  we  accomplish  our  object. 

A  further  circumstance  requiring  attention  is  the  faulty  position 
of  the  tibia,  that  may  have  resulted  from  caries  of  the  knee,  especially 
its  inclination  to  luxation  backward ;  it  is  always  difficult,  sometimes 
impossible,  to  correct  this  position  of  the  knee,  but  we  succeed  best 
by  making  the  extension  very  gradually ;  under  such  circumstances, 
forced  extension  would  induce  luxation  backward  —  then  perfect 
straightening  would  be  impossible. 

You  must  not  expect  that  the  knee  will  again  acquire  its  beautiful 
normal  shape,  even  if  it  be  quite  straight ;  tliis  never  occurs,  but,  as 
we  are  not  called  on  to  go  about  with  naked  knees,  as  the  Highlanders 
do,  the  shape  does  not  make  so  much  difference,  if  the  knee  be  only 
straight  and  firm  enough  to  walk  on.  Although  joints  with  tumor 
albus  may  be  brought  into  the  most  serviceable  position  at  almost  any 
time,  even  when  there  are  fistulae  present,  and  should  be  placed  in  a 
closed  bandage  or  knee-cap,  still,  the  period  when  fistulas  have  just 
closed,  and  the  cicatrices  are  fresh,  dense,  and  tender,  is  most  unfavor- 
able for  the  extension,  for  then  rupture  of  the  cutaneous  cicatrices 
and  new  suppuration  will  be  most  liable  to  occur.  In  such  cases  I 
now  never  resort  to  sudden  straightening  under  aneesthesia,  but  always 
employ  extension  by  weights. 

What  has  here  been  said  in  regard  to  straightening  the  knee-joint 
may  apply  equally  to  the  hip  and  ankle.  Anchyloses  of  the  shoulder 
and  elbow  have  a  totally  different  functional  significance  ;  in  them  the 
problem  is  to  restore  mobility,  and  this  cannot  be  obtained  by  break- 
ing up  the  anchylosis  and  applying  a  plaster-bandage. 

If,  on  straightening  a  knee,  where  there  have  been  few  adhe- 
sions, and  the  joint  is  tolerably  healthy,  we  wish  to  obtain  mobility, 


OPERATIONS  FOR  ANCHYLOSES.  611 

of  course  we  should  not  apply  the  plaster-bandage  after  the  operation, 
or,  at  least,  should  not  leave  it  on  long,  but  we  should  apply  instru- 
ments by  which  motion  may  be  made  some  time  after  the  extension ; 
this  motion  should  first  be  tried  under  anaesthesia,  and  subsequently 
repeated  daily  without  the  anaesthetic.  I  shall  not  deny  that  cases 
occur  where  a  tolerable  amount  of  motion  may  be  obtained  in  this 
way;  but  they  are  rare,  and  they  are  either  cases  where  stiffness 
has  remained  after  fractures  through  the  joint,  or  after  inflammations 
of  very  short  duration ;  I  could  almost  believe  that,  in  some  of  these 
cases,  mobility  would  have  been  restored  simply  by  daily  use,  hence  I 
have  no  very  brilliant  anticipations  about  the  results  of  straightening 
anchyloses  generally.  But  the  mere  fact,  that  we  may  now  almost 
entirely  erase  anchylosis  from  the  list  of  indications  for  amputation, 
is  a  very  great  triumph  over  former  surgery  ;  but  this  does  not  bar 
the  way  for  further  improvements  of  the  new  method,  or  for  the  at- 
tainment of  better  results. 

[Wharton  P.  Hood  (in  "  Bonesetting,"  London,  1871)  says  that 
partial  anchylosis  and  pain  on  motion  are  often  due  to  string-like  ad- 
hesions. A  painful  point  exists  somewhere  about  the  joint;  you 
should  press  on  this  with  the  thumb  of  the  left  hand,  while  steadying 
the  limb  above  the  joint,  then  with  the  right  hand  make  sudden  flexion 
and  rotation,  again  extend  the  limb  and  let  the  patient  use  it  at  once. 
Of  course  this  is  not  to  be  done  if  any  acute  inflammation  exists,  or 
in  scrofulous  subjects.] 

Cases  occur  where  the  mechanical  conditions  in  the  joint  are  of 
such  a  nature  that  the  ends  of  the  bones  cannot  be  brought  into  any 
different  position.  I  have  already  given  you  the  elbow-joint  as  an 
example ;  e.  g.,  the  case  is  one  of  arthritis  deformans,  the  fossas  at 
the  lower  end  of  the  humervis  above  the  trochlea  are  filled  with 
newly-formed  bone ;  here  it  is  impossible  to  move  the  ulna  forward  or 
backward ;  in  arthritis  deformans  similar  circumstances  occur  in  other 
joints,  hence  the  consequent  anchyloses  cannot  be  rendered  movable, 
any  more  than  they  can  after  true  arthritis,  therefore  both  diseases 
are  usually  contraindications  to  extension  of  the  anchjdosis.  Lastly, 
as  above  stated,  the  adhesions  of  the  ends  of  the  bones  may  be  bony, 
there  may  be  anchylosis  ossea ;  it  will  rarely  be  possible,  indeed,  except 
where  there  are  simply  a  few  osseous  bands,  to  break  such  anchyloses ; 
in  most  of  these  cases  the  anchylosis  will  stand  firm.  What  can  be 
done  in  such  cases  ?  There  are  two  ways  of  altering  the  position  of 
such  joints:  by  bending  the  bone  above  or  below  the  anchylosed 
joint,  or  by  sawing  out  a  piece  from  the  joint  or  from  the  bone.  Jn 
regard  to  the  first,  some  surgeons  would  shrug  their  shoulders  if  it 
were  proposed  as  a  method ;  still,  this  bending  or  even  fracture  of  the 


612  CHRONIC  INFLAMMATION   OF  THE  JOINTS. 

bone  has  often  been  done  unintentionally,  and  has  generallj^  turned 
out  well.  Several  times  in  extending  anchylosis  of  the  kuee-joint, 
once  in  the  hip-joint,  without  intending  it,  I  made  a  partial  or  com- 
plete fracture  of  the  bone  ;  the  joint  remained  as  before,  but  above 
the  knee  and  below  the  hip  the  bone  bent  so  as  to  compensate  for  the 
angle  at  which  the  joint  was  anchylosed,  and  straightening  was  prac- 
tically accomphshed,  although  not  by  rupture  of  the  anchylosis.  In 
all  these  cases  I  applied  the  plaster-bandage ;  the  course  was  just  the 
same  as  in  simple  subcutaneous  fractures,  the  pain  was  even  less 
than  after  breaking  up  anchyloses,  and  the  result  was  perfectly  satis- 
factory. I  cannot  see  why  we  should  reject  this  operation  of  substi- 
tuting a  fracture  of  the  bone  for  an  unsuccessful  attempt  at  straight- 
ening the  anchylosis,  and  I  should  much  prefer  it  to  fxny  resection  of 
the  knee  or  hip,  where  it  can  be  done  easily,  without  great  force  or 
hard  jerks ;  I  even  believe  that  we  should  always  try  to  substitute 
fracture  of  the  femur,  if  it  can  be  easily  broken,  for  resections  of  the 
knee  at  least,  no  matter  how  they  are  done ;  in  other  joints  resection 
is  of  course  to  be  preferred  for  various  reasons.  The  perfected  meth- 
ods of  extension  by  weights  not  onl}^  enable  us  to  improve  the  posi- 
tion in  most  cases  of  acute  and  chronic  inflammations  of  the  knee  and 
hip  joints  with  unexpected  facility,  thus  avoiding  angular  deformity  ; 
but  even  in  developed  anchyloses  they  prove  very  effectual,  except- 
ing^ of  course,  cases  where  there  is  bony  anchylosis.  Hence  extension 
by  weights  seems  to  come  more  into  use  and  to  be  an  adjuvant  to 
treatment  by  apparatus  as  well  as  by  brisement  forcL 

Tliere  are  three  methods  of  resecting  bony  anchjdosis :  1.  Jxlica 
Harton^s  {published  in  1825) ;  in  angular  anchylosis  of  the  knee, 
after  dividing  the  soft  parts,  close  above  the  joint,  you  saw  out  from 
the  femur  a  triangular  piece,  whose  base  is  upward,  and  whose  angle 
pointing  downward  must  compensate  the  angle  of  the  anchylosis  (we 
might  also  saw  this  piece  out  of  the  anchylosed  joint  itself)  ;  then 
the  limb  is  straightened,  the  joint  is  untouched,  the  distortion  is 
placed  in  the  thigh,  as  it  is  after  fracture  of  the  bone.  This  operation 
has  been  done  frequently  with  good  results  in  anchyloses  of  the  hip 
and  knee. 

2.  We  may  make  a  subcutaneous  osteotomy  through  the  anchylosed 
joint  after  B.  von  Lanyenheck^s  method  ;  this  operation,  which  we 
found  to  be  very  useful  in  fractures  that  had  united  obliquely  and  in 
rachitis  (page  247),  has  hitherto  been  little  used  in  bony  anchj-losis, 
hence  we  can  give  no  opinion  of  it.  Gross  has  employed  a  modified 
form  of  it  with  great  benefit ;  he  bores  obliquely  through  the  anchy- 
losis in  many  places,  and  divides  the  adhesions  with  fine  chisels. 


OPERATIONS  FOR  ANCHYLOSES.  613 

3.  Total  resection  of  the  joint.  I  have  abeady  stated  my  opinion 
about  tlie  admissibility  of  resection  for  anchylosis  of  the  hip  and 
knee-joints,  and  would  regard  it  as  ultimum  remedium  and  valde 
anceps ;  in  the  elbow-joint  the  prospect  is  rather  better;  here  by  re- 
section we  may  change  the  anchylosed  joint  into  a  movable  false  one, 
which  is  occasionally  quite  useful,  if  all  turns  out  well,  but  this  is  the 
point  on  which  all  depends,  and  which  we  cannot  always  master, 
Wlio  would  risk  his  life  for  a  stiff  elbow  ?  Moreover,  in  resections 
for  anchylosis  of  the  elbow,  the  results  have  not  always  been  very 
brilHant,  either  as  regards  mobility  or  life,  although  some  cases  seemed 
for  a  time  very  successful.  So  we  shoiald  not  be  too  free  with  these 
resections. 

In  the  shoulder,  the  circumstances  are  very  peculiar :  experience 
teaches  that  persons  with  stiff  shoulders  can,  by  constant  use,  make 
their  shoulder-blades  so  movable  that  the  stiffness  of  the  shoulder 
causes  comparatively  little  inconvenience  ;  in  such  a  case  it  would  be 
folly  to  operate. 

Patients  with  caries  of  the  wrist  are  usually  so  glad,  when,  after 
years  of  suffering,  the  disease  at  length  recovers,  that  they  do  not 
complain  of  their  stiff  hand ;  nevertheless,  successful  resections  of  an- 
chylosed wrists  have  been  recently  made  by  Ilose  ;  it  is  true,  the  final 
results  of  these  operations  are  not  yet  fully  known.  In  the  foot  there 
would  be  no  question  about  resection  for  anchylosis  in  a  bad  position ; 
usually  defect  of  the  ankle-bones  is  the  chief  cause  of  deformities  of 
the  foot  after  inflammation  of  the  joint.  It  will  depend  on  the  indi- 
vidual case  whether  the  foot  is  useful,  whether  a  correction  of  posi- 
tjon  be  possible,  or  if  a  good  stump  be  preferable. 


CHAPTER  XVIII. 

VONOENITAL  DEFORMITIES  OF  THE  JOmTS,  DUE  TO  MVS 
CULAR  AND  NERVOUS  AFFECTIONS  AND   CICATRI- 
CIAL  CONTRA  CTIONS—L  OXARTEROSES.' 


LECTURE    XL II. 

I.  Deformities  of  Intra-uterLne  Origin  due  to  Disturbances  of  Development  of  the  Joint.— 
II.  Deformities  occurring  only  in  Children  and  Young  Persons,  caused  by  Impaired 
Growth  of  the  Joint.— III.  Deformities  from  Contractions  or  Paralysis  of  Single 
Muscles  or  Groups  of  Muscle*.- IV.  Limitation  of  Movement  in  the  Joints  from 
Contraction  of  Fasciae  and  Ligaments. — V.  Cicatricial  Contractions. —  Treatment: 
Extension  by  Apparatus. — Straightening  during  Aiiresthesia. — Compression. — Te- 
notomy and  Myotomy. — Division  of  the  Fasciae  and  Articular  Ligaments. — Gym- 
nastics and  Electricity. — Artificial  Muscles.— Supporting  Apparatus. 

Gentlemen  :  To  day  we  have  to  speak  of  those  deformities  not 
resulting  from  primary  disease  of  the  joint,  but  leading  to  abnormal 
mechanical  conditions,  if  the  articular  surfaces  from  various  causes 
assume  abnormal  forms,  or  if  while  the  form  remains  normal  the  move- 
ments be  impaired  in  some  direction  by  obstacles  due  to  abnormal 
states  of  the  muscles,  fasciae,  tendons,  or  skin.  Most  of  the  cases  are 
of  stiffness,  deformity,  or  limitation  of  motion  of  the  joint,  exterior  to 
the  synovial  membrane.  In  this  section  I  follow  chiefly  the  division 
of  Volkmann,  whose  extraordinary  work  on  this  subject,  published 
in  JSillroth  and  Von  Pitha's  Archives,  I  cannot  too  strongly  urge 
your  studying. 

I.  DEFORMITIES  OF  EMBRYONAL  ORIGIN,  DUE   TO    DISTURBED    DEVEL- 
OPMENT  OF  THE  JOINT. 

These  distortions  are  alwaj's  congenital ;  they  are  much  the  most 
frequent  in  the  foot,  especially  as  club-foot^  pes  varus  sen  equino- 
varus.  Although  we  may,  and  formerly  did,  term  all  distortions 
where  the  foot  was  drawn  together  into  a  "  clump  "  as  club-foot,  we 

>  From  Xofos,  oblique,  apBpov,  member,  joiot. 


CLUB-FOOT,  ETC.  615 

now  generally  mean  by  this  term  only  the  forms  where  the  inner 
border  of  the  foot  is  raised,  while  the  plantar  surface  is  usually  flexed, 
and  in  children  it  cannot  be  brought  into  the  normal  position,  unless 
with  the  greatest  difficulty.  If  children  born  with  such  feet  (both 
feet  are  usually  affected)  learn  to  walk,  they  step  on  the  outer  side 
of  the  foot ;  this  rolls  more  and  more  inward,  becomes  flat,  the  hol- 
low of  the  foot  is  contracted,  the  middle  and  anterior  part  of  the  foot 
are  not  well  developed,  the  joints  become  anchylosed  and  the  feet 
become  misshapen  clubs  ;  the  outer  part  of  the  back  of  the  foot  is  the 
part  walked  on,  and  at  that  point  a  thick  callosity  forms  with  a  mu- 
cous bursa  under  it;  as  the  foot  is  not  moved,  the  muscles  of  the 
leg  atrophy,  so  that  little  besides  skin  and  bone  is  left ;  this  causes 
the  resemblance  to  a  horse's  hoof.  Various  grades  of  club-foot  have 
been  distinguished,  from  the  trifling  deformity  just  after  birth  to  that 
just  described.  It  is  to  be  remarked  that  the  higher  grades  of  club- 
foot result  from  walking ;  if  the  patient  never  got  on  his  feet,  the  con 
genital  deformity  would  probably  change  little,  if  any. 

The  most  varied  hypotheses  have  been  advanced  as  to  the  causes 
of  congenital  club-foot.  The  typical  form  of  this  congenital  deformity 
appears  to  indicate  that  it  depends  on  disturbance  of  a  typical  devel- 
opment of  the  lower  extremities ;  for  if  foetal  disease,  disturbance  of 
an  irritative  nature,  or  abnormal  pressure  in  the  uterus,  were  at  fault, 
cases  would  probably  differ,  as  we  shall  see  hereafter.  The  following 
views,  recently  published,  seem  to  me  very  important  in  the  explana- 
tion of  this  deformity.  Eschricht  has  shown  that  at  the  commence- 
ment of  their  development  the  lower  extremities  lie  with  their  backs 
against  the  abdomen,  the  hollows  of  the  knees  being  against  the  belly ; 
so  during  the  earlier  months  the  legs  must  rotate  on  their  axes,  and 
the  toes,  which  pointed  backward,  must  point  in  the  opposite  direc- 
tion. If  the  embryonic  extremities  lie  so  close  as  to  apjiear  united 
under  a  common  skin,  or  be  really  united,  the  above-mentioned  rota- 
tion of  the  limbs  cannot  occur,  and  in  this  deformity  {siren)  the  feet 
are  turned  directly  backward.  This  rotation  on  the  axis,  which  was 
arrested  in  the  above  case,  does  not  take  place  fully  in  club-foot, 
the  rotation  in  the  foot  is  not  fully  accomplished.  According  to  this, 
congenital  club-foot  would  come  among  cases  of  obstructed  develop- 
ment ;  about  its  cause  we  know  as  little  as  we  do  of  other  deformities 
of  the  same  class.  The  abnormal  forms  observed  by  Siceter,  espe- 
cially the  obliqueness  of  the  ankle-bonesj  unsuitable  length  of  the  mus- 
cles, among  which  shortness  of  the  gastrocnemius  is  the  most  con- 
spicuous and  longest  known,  must  be  regarded  as  consequences  of 
this  faulty  direction  of  the  foot  in  utero,  which  is  subsequently  in 
creased.     This  explanation,  based  on  accurate  observation,  is  so  much 


616  CONGENITAL  DEFORMITIES  OF  THE  JOINTS,   ETC. 

more  satisfactory  than  tlie  previous  hypothetical  explanations,  which 
mostly  referred  the  affection  to  foetal  myelitis,  with  consecutive  paral- 
ysis and  contraction,  that  the  latter  scarcely  deserve  mention  except 
for  their  historical  interest. 

Some  other  congenital  deformities  of  the  feet  are  proved  to  be 
due  to  abnormal  positions,  and  especially  to  abnormal  pressure. 
VolJcmmm  has  collected  some  very  interesting  observations  on  this 
point;  but  these  cases  differ  among  themselves,  showing  that  there 
was  something  accidental  in  their  occurrence.  In  still  other  cases 
large  portions  of  bone  remained  undeveloped,  e.  g,,  the  lower  end  of 
the  tibia,  fibula,  or  radius,  or  the  whole  radius  (manus  vara). 

In  the  spinal  column,  lateral  halves  of  the  vertebrse  sometimes  do 
not  develop  fully,  or  superfluous  pieces  maj'  be  formed,  causing  lat- 
eral curvature  (scoliosis)  ;  but  these  congenital  cases  of  curvature  are 
very  rare  ;  the  Vienna  collection  has  a  few  of  these  rare  specimens. 
Lastly,  we  must  here  mention  the  faulty  development  of  the  sterno- 
cleido-mastoid  muscle,  w^hich  is  not  rarely  congenital  and  is  quite 
typical ;  the  vertebrae  remain  normal,  so  far  as  is  known  ;  we  know 
nothing  of  the  causes  of  this  deformity  ;  the  hypotheses  1  have  seen 
seem  to  me  scarcely  probable. 

II.  DEFORMITIES   DEVELOPING   ONLY  IN    CHILDREN  AND  YOUNG    PER- 
SONS, CAUSED  BY  DISTURBED  GROWTH  OF  THE  JOINTS. 

AU  conditions  of  the  body,  such  as  standing,  walking,  sitting,  etc., 
depend  on  the  forms  of  the  joints  and  their  ligaments,  and  on  muscu- 
lar action.  The  effect  of  the  latter  on  all  our  positions,  even  in  the 
way  we  lie,  you  may  best  perceive  by  trying  to  give  a  certain  position 
to  a  cadaver,  from  which  the  rigor  mortis  has  passed  away ;  you 
would  then  see  that  we  rarely  take  the  natural  jDOsitions  given  by  the 
form  of  the  joints  and  ligaments,  but  generally  aid  them  by  the  mus- 
cles. Persons  whose  muscles  tire  easily,  from  weakness,  exhaustion 
from  disease,  or  lack  of  exercise,  in  assuming  any  position  will  of 
course  seek  the  one  most  natural,  and  requiring  least  muscular  action. 
The  articular  pressure  due  to  muscular  action  is  always  evenly  dis- 
tributed over  the  whole  articular  surface,  and,  when  this  action  dimin- 
ishes or  ceases,  individual  parts  of  the  ends  of  the  bones  forming  the 
joint  have  to  bear  all  the  pressure.  If  the  bones  were  fully  developed 
and  firm,  this  unusual  burden  would  have  no  further  results,  if  it  were 
of  short  duration.  But  when  growing  bones,  which  are  still  soft,  and 
will  remain  so  for  a  time  till  their  forms  are  fully  developed,  are  re- 
peatedly and  for  a  long  time  exposed  to  pressure,  acting  on  the  same 
point,  the  form  of  the  articular  surface  and  of  the  articular  ligaments 
gradually  changes;   the   bones  also  sometimes  fall  into  a  state  of 


DISTURBED   GROWTH   OF   THE   JOINTS.  617 

pathological  softening,  accompanied  bj  pain  and  the  disturbances  of 
growth  in  the  ends  of  the  bones  caused  by  the  abnormal  burden,  in- 
crease rapidly  ;  there  is  a  corresponding  change  in  the  ligaments  and 
muscles,  and  the  changes  begun  here,  react  on  the  form  and  develop- 
ment of  the  entire  skeleton.  The  most  important  examples  of  this 
are  scoliosis,  genu  valgum,  and 2)es 2ylcinus. 

By  "  scoliosis  "  (from  OKoXiog,  curved)  we  mean  the  state  of  the 
spinal  column,  where  it  is  constantly  bent  to  one  side,  and  where  this 
curvature  has  become  permanent.  As  already  mentioned,  such  a  po- 
sition may  arise  from  abnormal  formation  of  the  vertebrse  ;  it  may  also 
be  due  to  enormous  distention  of  one  side  of  the  thorax  from  pleuritic 
effusion,  or  to  collapse  of  one  side  of  the  chest  from  reabsorption  or 
evacuation  of  such  effusion,  or  lastly  to  fixation  of  the  pelvis  in  an 
oblique  position,  either  from  apparent  or  real  shortening  of  a  leg  after 
a  joint  or  bone  disease,  or  other  cause.  All  these  are  relatively 
rarely  the  causes  of  the  scolioses  of  which  we  are  here  treating  ;  these 
usually  occur  in  young  girls  shortly  before  puberty.  These  curva- 
tures have  a  typical  form  ;  as  a  rule  the  lumbar  portion  of  the  spinal 
column  is  convex  to  the  left,  and  the  upper  dorsal  portion  is  convex 
to  the  right.  It  is  a  matter  of  dispute  whether  the  lower  or  upper 
curvature  comes  first ;  whether  the  first  is  the  primary  and  the  latter 
secondary  or  compensatory,  or  the  reverse ;  as  a  rule  we  find  both 
ciirvatures  from  the  start,  they  probably  develop  about  the  same  time. 
Tf  the  faulty  position  remain  unobserved  and  without  treatment,  and 
the  unfavorable  conditions  continually  increase,  the  right  scapula  is 
elevated  (the  first  marked  symptom),  and  as  the  vertebrae  gradually 
rotate  the  deformity  constantly  increases,  the  upper  part  of  the  spine 
projects  as  a  gibbosit}',  the  position  of  the  head  changes  correspond- 
ingly, the  thorax  is  displaced,  in  short  a  hump-back  is  developed. 
From  anatomical  reasons,  which  have  been  carefully  traced  by  IT. 
Meyer,  the  protrusions  of  the  spine  posteriorly  (cyphosis,  from  Kvcpog, 
gibbosity)  always  accompany  high  grades  of  curvature,  so  these  de- 
formities are  also  called  "  cypho-scolioses."  Most  old  persons  with 
humps  belong  to  this  class ;  patients  with  caries  of  the  vertebrae 
rarely  attain  old  age ;  hence,  we  only  see  the  so-called  Pott's  curv^a- 
ture  caused  by  caries  of  the  vertebrse,  in  children  and  very  young  per- 
sons. The  chief  cause  of  scoliosis  is  weakness  of  the  spinal  muscles  ; 
as  long  as  feeble  children  are  left  entirely  to  themselves,  and  can  lie 
down,  sit,  walk,  or  run,  as  they  wish,  and  as  long  as  they  feel  like  it, 
scoliosis  rarely  develops ;  but  when  they  are  made  to  occupy  certain 
tiresome  positions  for  hours,  as  in  writing,  reading,  sewing,  playing 
the  piano,  etc.,  they  will  seek  positions  where  the  muscles  for  keep- 
ing the  body  erect  are  used  the  least.     These  positions  become  cus- 


618  CONGENITAL  DEFORMITIES  OF  THE  JOINTS,   ETC. 

tomarj  or  habitual.  When  the  children  are  sitting,  even  without 
occupation,  and  politeness  forbids  their  lounging,  they  support  them* 
selves  with  one  hand  on  the  seat;  if  they  stand,  they  lean  so  that  the 
body  does  not  need  to  be  supported;  they  usually  stand  on  one  leg, 
to  rest  the  other.  If  the  curvature  of  the  spinal  column  has  existed 
for  months  or  years,  the  centre  of  gravity  of  the  back  and  head 
changes  more  rapidly,  and  the  deformity  progresses  more  quickly. 
At  first,  the  intervertebral  cartilages  are  merely  compressed  on  one 
side,  then  they  become  relaxed  on  the  other  side,  grow  thicker,  and 
the  bodies  of  the  vertebrae  are  compressed"  more  and  more,  till,  from 
being  cylindrical,  they  become  conical.  This  compression  sometimes 
also  leads  to  inflammatory  new  formations,  to  deposits  of  osteophytes, 
occasionally  even  to  ossification  of  the  ligaments. 

Genu  valgum^  or  baker's  leg,  is  a  deformity  of  the  knee-joint, 
where  its  shape  is  such  that  the  leg  forms,  with  the  thigh,  an  obtuse 
angle  externally  ;  if  these  patients  lie  on  the  back,  placing  the  inner 
sides  of  the  knees  together,  the  feet  will  stand  far  apart ;  to  place  the 
inner  borders  of  the  feet  together  they  must  cross  the  knees.  This 
deformity  occurs  most  frequently  in  young  males,  who  during  the 
whole  day  have  to  move  their  bodies  and  arms  while  standing,  and 
at  the  same  time  have  to  bend  their  knees ;  bakers',  locksmiths',  and 
cabinet-makers'  apprentices  are  especially  predisposed  to  this  affec- 
tion, which  is  very  painful  when  it  is  excessive  or  increasing  rapidly. 
The  external  condyle  is  strongly  compressed,  the  internal  lateral  liga- 
ment much  stretched,  the  external  lateral  ligament  contracted,  and 
the  biceps  muscle  is  shortened  and  becomes  tense. 

Flat-foot,  pes  planus,  is  a  deformity  of  the  foot,  frequently  affect- 
ing 3'oung  girls  as  well  as  boys  before  the  age  of  puberty,  when  they 
have  to  stand  much.  The  bones,  which  form  an  arch  at  the  inner 
margin  of  the  foot,  sink  down  so  that  the  sole  of  the  foot  becomes 
perfectly  flat,  or  even  convex  downward ;  then  the  outer  border  of 
the  foot  is  elevated  (pes  valgus),  and  the  peronei  muscles  are  short- 
ened, their  points  of  insertion  being  approximated.  This  deformity 
of  the  foot  is  very  frequent ;  it  often  follows  genu  valgum,  but  oftener 
is  independent ;  sometimes  it  comes  on  very  rapidly  and  with  severe 
pain. 

While  I  consider  the  above-mentioned  continued  pressure  on 
growing  bones  as  the  essential  cause  of  scoliosis,  genu  valgum,  and 
pes  planus,  still  we  cannot  fail  to  notice  that  only  a  few  of  the  per- 
sons subjected  to  these  injurious  influences  are  affected  with  the 
above  deformities,  so  that  we  are  naturally  led  to  suppose  that  besides 
the  muscular  weakness  there  must  be  a  special  weakness  of  the  os- 
seous system,  a  softness  of  the  bones ;  indeed,  I  cannot  help  think- 


PARALYSES  OF  MUSCLES.  619 

wg  that  there  is  a  slight  amount  of  rachitis.  Zorinsen  and  some 
other  authors  claim  that  the  above  cause  is  very  prominent  in  the  eti- 
ology of  curvature  of  the  spine.  Bueter,  Henke,  and  other  authors, 
claim  that  in  all  these  deformities  the  articular  sui-faces  grow 
obliquel}'  and  uneven ;  this  certainly  has  much  to  do  with  the  in- 
crease of  the  disease,  but  can  scarcely  be  recognized  as  a  cause.  The 
results  of  recent  investigations  render  it  improbable  that  (idiopathic) 
contraction  and  relaxation  of  the  articular  ligaments  cause  these  de- 
formities, as  1  was  formerly  inclined  to  believe,  although,  from  the 
displacement  and  deformity  of  articular  surfaces  of  the  bones,  they 
must  occur. 


m.  DEFORMITIES   DUE    TO    CONTRACTIONS  OR   PARALYSES   OF  SINGLE 
MUSCLES   OR   GROUPS   OF  MUSCLES. 

This  class  of  cases  is  very  numerous.  Acute  inflammations  in 
muscular  substance,  or  in  the  immediate  vicinity  of  muscles  under 
tense  fascias,  may  cause  contractions  simply  by  rendering  the  stretch- 
ing of  the  inflamed  muscle  very  painful.  It  is  very  common  in  deep 
abscesses  of  the  neck  to  find  the  head  inclined  to  the  afi"ected  side,  so 
that  the  patient  is  entirely  unable  to  straighten  it ;  and  this  can  only 
be  done  under  anaesthesia,  when  it  is  readily  accomplished.  I  once 
saw  a  foot  fixed  in  the  position  of  pes  equinus  by  an  abscess  in  the  mus- 
cles of  the  calf  of  the  leg.  Acute  inflammation  of  the  psoas  muscle 
(psoitis  and  peri-psoitis)  often  causes  the  hip-joint  to  be  flexed  at  an 
acute  angle.  When  the  pus  is  evacuated  these  contractions  diminish, 
and  often  gradually  disappear  entirely ;  but  sometimes  the  cicatrix 
is  so  large  that  it  continues  the  contraction,  which  is  afterward  re- 
moved with  difficulty. 

Secondly,  direct  nervous  irritation  from  disease  of  the  nervous 
centres  may  cause  permanent  contractions ;  when  these  cases  start 
from  the  brain,  they  ofi"er  very  little  chance  for  treatment.  In  caries 
of  the  spinal  column  and  transfer  of  the  inflamaiation  to  the  anterior 
roots  of  the  spinal  nerves,  muscular  contractions  and  paralysis  of  the 
limbs  sometimes  occur  simultaneously  ;  in  one  such  case  I  saw  a 
nearly  complete  cure  occur  spontaneously. 

Reflex  paralysis  may  also  occur.  I  have  seen  such  cases  where 
the  thigh,  hand,  and  foot,  were  afi"ected,  particularly  in  young  women ; 
in  some  cases  these  contractions  were  induced  by  falls  on  the  parts, 
in  others  by  irritation  of  the  genital  system  (hysterical  contractions). 
These  cases  relax  during  sleep  and  anaesthesia. 

Lastly,  we  come  to  the  most  frequent  of  all  of  these  groups,  the 
Bo-called  paralytic  contractions,  such  as  occur  after  partial  or  total 


620  COXGENITAL   DEFORMITIES   OF   THE   JOINTS,   ETC. 

paralysis  from  meningitis  and  encephalitis,  especially  in  children. 
These  contractions  occur  on  one  or  both  sides,  chiefly  in  the  lower 
extremities.  From  its  mechanical  construction  a  completely  paralyzsd 
le<>-  hanffs  and  lies  with  the  foot  extended,  and  turned  somewhat  in- 
ward  ;  of  this  you  may  convince  yourself  by  examining  any  cadaver 
which  is  not  rigid.  If  the  foot  be  not  purposely  brought  out  of  this 
position,  it  becomes  gradually  fixed  there,  partly  by  the  ligaments  on 
the  back  of  the  foot,  the  muscles  of  the  calf,  tendo  achillis,  and  super- 
jacent fasciae  atroi^hying,  partly  by  the  slower  growth  of  these  parts ; 
gradually  also  the  articular  surfaces  and  the  form  of  the  bones  change 
as  a  result  of  unequal  pressure,  as  previously  explained,  and  it  becomes 
more  difficult  and  at  last  impossible  to  bring  the  foot  into  a  right-an- 
gled position ;  in  attempting  to  eflPect  this  the  resistance  from  the 
muscles  and  tendons  is  most  readily  perceived,  hence  the  opinion  that 
the  gastrocnemius  muscle  and  the  tendo  achillis  were  contracted,  even 
in  cases  where  it  was  just  as  much  paralyzed  as  the  other  muscles  of 
the  leg.  Then  it  was  thought  that  only  the  extensor  muscles  were 
fully  paralyzeil,  while  the  antagonists  preserved  some  innervation,  so 
that  they  alone  acted  on  the  foot  and  attained  a  relative  preponder- 
ance. Thus  arose  the  theory  of  antagonistic  contractions  taught 
especially  by  Delpech ;  which  was  sustained  chiefly  by  those  cases 
where  there  was  really  an  unequal  distribution  of  paresis  and  paraly- 
sis of  the  different  groups  of  muscles.  It  was  Hueter  who  first  called 
attention  to  the  fact  that  it  was  chiefly  tlie  continued  position  as- 
sumed by  the  paralyzed  limb,  from  its  weight,  that  induced  the  con- 
tractions, and  that  these  so-called  antagonistic  contractions  were  not 
at  all  muscular  actions,  but,  as  in  congenital  club-foot,  were  due  to 
atrophy  and  lack  of  growth.  After  investigating  this  view,  I  must 
entirely  agree  with  it.  I  had  often  met  cases  where  the  theory  of 
antagonistic  contractions  seemed  doubtful ;  as  in  one  case  where  at 
the  battle  of  Sadowa  a  soldier  was  shot  through  the  right  forearm 
and  had  the  radial  nerve  torn ;  four  years  subsequently  there  was  to- 
tal paralysis  of  all  the  parts  supplied  by  that  nerve,  but  not  a  sign  of 
antagonistic  contraction.  If  w^e  carry  our  investigations  to  paralyzed 
limbs,  we  find  that,  in  cases  where  the  patients  sit  all  day  with  the  leg 
and  thigh  flexed,  contractions  take  place  at  the  knee  and  hip,  but,  if 
the  patients  with  partly  paralyzed  limbs  still  have  strength  enough 
to  move  about  with  support,  the  movements  of  the  joints  continue  up 
to  a  certain  point.  This  also  you  may  best  see  on  a  cadaver  that  is 
not  rigid  ;  the  foot  placed  on  the  ground,  with  the  body  resting  on  it, 
turns  outward  (pes  plano-valgus  paralyticus),  the  knee  bends  for- 
ward and  outward  (genu  antecurvatum),  while  at  the  hip  the  body 
falls  forward  till  it  is  supported  by  the  sound  leg,  crutches,  or  cane 


SHORTEXING   OF   THE   FASCLE,   ETC. 


621 


Thus,  from  the  weight  of  the  body,  the  limbs  assume  positions  which 
gradually  become  permanent  {Volhnann),  and  in  young  persons 
have  a  decided  influence  on  the  forms  of  the  articular  surfaces.  All 
these  conditions  may  be  most  naturally  explained  on  mechanical  prin- 
ciples, while  formerly  the  most  complicated  theories  eere  based  on 
very  slight  grounds,  when  any  explanation  was  attempted. 


IV.  LIMITATIONS    OF  MOTION    IN  JOINTS    CAUSED    BY  SHORTENING  OF 
FASCLE  AND    LIGAMENTS. 

Any  long-continued  fixed  position  of  a  joint,  even  if  not  due  to 
the  above-described  diseases  of  muscles  and  nerves,  may  lead  to  short- 
ening of  the  fasciae.  A  man  who  kept  his  left  leg  and  thigh 
flexed  for  a  year  and  a  half,  on  account  of  suppuration  of  the  inguinal 
jglands,  was  brought  to  our  clinic  after  the  bubo  had  healed,  because 
he  could  not  extend  the  leg.  This  is  particularly  true  of  the  fascia 
lata,  which  from  a  few  months  of  quiet  may  become  so  rigid  that  it  is 
sometimes  impossible  to  extend  it  again.     After  coxitis  has  run  its 

Fig.  109. 


Contraction  of  the  fascia  lata  from  coxitis,  after  Froriep. 


course,  when  the  joint  has  become  perfectly  healthy,  this  contraction 
of  the  fascia  may  prove  a  permanent  obstruction  to  complete  exten- 
sion, so  that  such  patients  may  occasionally  limp  for  life ;  which  is 
another  important  reason  for  paying  special  attention  to  the  position 
of  the  limbs  in  inflammation  of  the  joints. 


622 


CONGENITAL   DEFORMITIES   OF   THE   JOINTS,   ETC. 


V.  DEFORMITIES   CAUSED   BY   CICATRICES. 

We  have  already  spoken  frequently  of  the  contraction  of  cica- 
trices ;  it  results  from  the  inflammatory  new  formation  in  the  wound 
gradually  giving  oif  water,  as  the  original  gelatinous  formation  by 
degrees  atrophies  to  dry  connective  tissue,  and  contracts  like  any  body 
that  is  drying  up.     The  larger  the  surface  of  the  cicatrix,  the  stronger 


Fig.  no. 


Via.  111. 


Cicatricial  contractions  after  bums. 


will  be  the  contraction  in  all  directions  ;  all  wounds  with  extensive 
loss  of  skin  will  be  followed  by  extensive  cicatricial  contraction,  and, 
as  this  is  generally  greatest  after  burns,  cicatrices  from  this  cause  are 
usually  the  ones  that  contract  most.  Of  course  it  depends  greatly  on 
the  position  of  the  cicatrix  whether  it  shall  produce  injurious  results, 
deformities  or  distortions.  Cicatrices  on  the  flexor  side  of  the  joint, 
when  they  extend  far  longitudinally,  may  prevent  full  extension  of 
the  limb.  Extensive  cicatrices  in  the  neck  induce  distortion  and 
fixation  of  the  head  to  the  injured  side ;  those  on  the  cheek  may  dis- 
tort the  mouth  or  lower  eyelid ;  on  the  back  of  the  hand  or  foot,  or 
about  the  finger-joints,  they  may  render  the  finger  immovable,  or  par- 
tially so. 

But  cicatrices  of  the  deeper  parts,  as  of  the  muscles  and  tendons, 


TREATMENT   OF   COXTRACTIOXS.  G23 

may,  of  course,  also  cause  deformities ;  as  necrosis  readily  follows  in 
jury  of  a  tendon,  and  cicatricial  tissue  replaces  the  tendon,  such  a 
part  as  a  finger,  when  injured,  becomes  crooked  and  stiff. 


Although,  in  what  has  just  been  said,  we  have  spoken  chiefly  of 
the  etiology  of  deformities,  still  the  diagnosis  is  included  there ;  and 
it  is  unnecessary  to  pursue  this  point  further.  Of  course  the  prog- 
nosis depends  entirely  on  the  possibility  of  removing  the  causes,  and 
the  treatment  also  varies  greatly  with  the  latter. 

To  remove  contractions,  the  most  natural  thing  is  to  stretch  the 
parts ;  we  may  try  this  by  having  the  contracted  limb  stretched  a  few 
times  daily.  But  this  so-called  manipulation^  which  is  very  effica- 
cious, requires  much  strength  and  patience  ;  hence  it  seems  better  to 
make  this  extension  by  the  regular  action  of  a  machine.  The  ex- 
tending machines  now  used  depend  on  the  combined  action  of  the 
screw  and  cog-wheel,  a  mechanism  that  has  been  employed  in  surgical 
instruments  from  the  most  ancient  times  ;  the  machines  may  be  vari- 
ousl}^  constructed,  but  must  be  light,  firm,  and  well  padded ;  they 
should  never  press  too  hard,  and  be  made  to  retain  any  position  ;  such 
machines  are  most  readily  made  for  the  knee  and  elbow ;  in  the  shoul- 
der and  hip  it  is  diflScult  to  fix  the  scapula  and  pelvis.  Extension 
may  be  made  under  anaesthetics,  to  hasten  the  progress ;  but  then 
avoid  using  too  much  force,  and  especially  bear  in  mind  that  cica- 
tricially -contracted  muscles  are  less  distensible  than  normal  ones,  and 
can  only  be  stretched  gradually.  Mechanical  extension  can  scarcely 
be  applied  to  those  muscular  contractions  depending  on  neuroses,  or, 
at  most,  it  can  only  be  used  as  an  adjuvant ;  the  cliief  treatment  must 
be  directed  to  the  nervous  affection  that  has  caused  the  muscular 
contraction.  Not  unfrequently  these  contractions  entirely  disappear 
under  chloroform,  especially  when  of  a  reflex  character,  in  the  same 
way  that  they  subside  spontaneously  in  acute  articular  inflammations, 
as  soon  as  the  patient  is  narcotized ;  the  flexed  knee,  for  instance, 
may  then  be  extended  without  the  least  force.  According  to  MemaJc^ 
many  contractions  disappear  under  the  use  of  the  constant  current  of 
electricity ;  as  many  excellent  men  are  now  engaged  studying  the 
constant  current,  it  is  to  be  hoped  that  the  mystery,  which  has  until 
lately  shrouded  this  subject,  may  disappear  before  clear  criticism. 
Treatment  by  apparatus  {prthopedy)  is  particularly  used  in  contrac 
tions  of  ligaments  and  fasciae.     Contractions  from  cicatrices  may  be 


624  CONGENITAL  DEFORMITIES  OF  THE  JOINTS,   ETC. 

improved,  but  rarely  entirely  cured,  by  stretching  the  cicatrix ;  a 
more  potent  remedy  here  is  continued  pressure,  made  by  adhesive 
plaster,  bandages,  or  compresses,  applied  to  suit  each  case.  The 
atrophy  of  the  cicatrix,  which  occurs  spontaneously,  in  the  course 
of  years  is  much  promoted  by  this  treatment.  Distention  is  com- 
bined with  compression  in  tlie  treatment  of  ring-shaped  cicatricial 
contractions  of  canals,  so-called  strictures,  such  as  occur  chiefly  in 
the  urethra  and  oesophagus,  by  the  introduction  of  elastic  sounds 
(called  bougies  because  they  were  formerly  made  of  wax)  of  gradu- 
ally-increasing thickness. 

The  orthopedic  treatment  previously  mentioned  does  not  always 
succeed,  or  at  least  is  often  very  slow,  hence  even  in  the  middle  ages 
the  tendons  of  the  contracted  muscles  or  the  muscles  themselves  were 
divided ;  this  operation  is  called  "  tenotomy,"  or  "  myotomy ;  "  the 
former  is  far  the  more  frequent.  Formerly  the  operation  was  done  by 
simply  incising  the  skin  down  to  the  tendon,  then  di\-iding  the  latter, 
and  letting  the  wound  heal  by  suppuration ;  the  results  were  not  very 
brilliant :  the  suppuration  was  sometimes  very  extensive,  thick  cica- 
trices formed,  which  could  only  be  slowly  stretched.  This  operation 
was  first  made  really  serviceable  by  Stromeyer,  who  taught  us  to 
divide  tendons  subcutaneously,  a  method  which  Dieffenhacli  intro- 
duced extensively  into  practice,  and  which  is  now  exclusively  used. 
I  shall  first  describe  this  operation  briefly  before  passing  to  its  results. 
Let  us  take,  as  an  illustration,  tenotomy  of  the  tendo  Achillis,  which 
is  the  most  frequent.  For  this  operation  you  may  best  employ  Dieffen- 
hacJi's  tenotome,  a  slightly-curved,  pointed,  narrow  knife.  The  pa- 
tient lies  on  the  belly,  an  assistant  holds  his  leg  firmly  at  the  calf; 
with  your  left  hand  you  seize  the  club-foot;  with  your  right  hand 
introduce  the  knife,  flatwise,  by  the  side  of  the  tendon  under  the  skin, 
and  over  the  tendon,  till  you  have  passed  beyond  the  tendon,  without, 
however,  perforating  the  skin  a  second  time ;  now  tm-n  the  edge  of 
the  knife  toward  the  tendon  and  divide  the  latter — when  so  doing  you 
will  hear  a  crackling  sound ;  as  the  division  is  completed,  you  will 
feel  with  the  left  hand  that  the  foot  is  more  movable ;  you  now  care- 
fully draw  out  the  knife.  Only  the  point  of  entrance  of  the  knife  is 
visible  externally,  the  tendon  has  been  divided  subcutaneously.  This 
metliod  of  subcutaneous  tenotomy  from  icithout  inicard  is  easier  for 
beginners,  because  in  it  there  is  no  danger  of  dividing  the  skin  more 
than  is  necessary.  Tenotomy  from  within  outward  is  more  elegant 
and  better  suited  for  some  cases.  The  foot  is  held  as  above,  and  the 
knife  is  entered  the  same  way,  but  it  is  then  passed  under  the  tendon 
and  the  cutting  edge  turned  toward  the  tendon ;  the  thumb  of  the 


TENOTOMY.  625 

rignt  hand  should  be  placed  over  the  point  of  the  knife  to  feel  it  and 
prevent  passing  it  through  the  skin ;  we  then  press  on  the  knife  and 
draw  it  from  within  outward  through  the  tendon  ;  being  careful  not  to 
let  it  cut  through  the  skin  when  the  jerk  occurs  that  accompanies  the 
completion  of  the  division.  This  method  seems  more  difficult  than  it 
is,  but,  like  any  operation,  it  requires  practice  on  the  cadaver.  When 
the  tenotomy  is  completed,  there  is  usually  but  little  bleeding  fi-om 
the  puncture,  though  sometimes  there  maybe  considerable,  as  in  some 
persons  a  tolerably  large  branch  of  the  posterior  tibial  artery  runs 
alongside  of  the  tendon,  and  is  divided  with  it.  If  the  bleeding  be 
slight,  a  piece  of  ichthyocoUa-plaster  may  be  placed  over  the  puncture, 
and  rendered  firmer  by  collodium ;  if  the  haemorrhage  be  more  profuse, 
the  puncture  should  be  covered  with  a  small  compress,  and  the  foot 
bandaged  as  high  as  the  calf;  the  bleeding  then  ceases.  This  dressing 
should  be  replaced  by  plaster  after  twenty-four  hours.  The  healing 
is  almost  always  by  first  intention ;  the  puncture  is  closed  in  three  or 
four  days.  But  there  may  be  suppuration ;  then  the  wounded  part 
grows  red,  swollen,  sensitive ;  blood  mixed  with  pus  flows  from  the 
wound,  an  abscess  often  forms  on  the  opposite  side ;  this  must  be 
opened,  and,  although  this  siappuration  is  not  dangerous  to  life,  it 
may  continue  two  or  three  Aveeks,  and  much  impair  the  results  of  the 
operation,  for  it  is  a  long  time  before  the  resulting  thick  cicatrix  is 
suited  for  extension.  Immediately  after  the  tenotomy,  at  the  point 
of  division  you  may  feel  a  hollow,  as  the  muscle  contracts  after 
division  of  the  tendon ;  this  hollow  disappears  in  the  course  of 
twenty-four  hours,  and  for  a  few  days  it  is  even  replaced  by  a  swell- 
ing ;  the  latter  gradually  subsides,  and  in  fourteen  days  at  most,  after 
a  normally-healed  tenotomy,  the  tendon  appears  perfectly  restored. 
The  course  of  this  healing  has  been  carefully  studied  experimentally ; 
formerly  it  was  supposed  there  was  something  very  peculiar  about  it ; 
I  have  often  made  these  experiments  on  animals,  and  find  that  healing 
takes  place  as  it  usually  does,  and  most  resembles  that  process  in 
nerves  and  bones.  When  the  tendon  is  divided,  and  the  muscle  con- 
tracts, there  would  be  an  empty  space  at  the  point  of  division  if  the 
external  atmospheric  pressure  did  not  at  once  press  the  surrounding  cel- 
lular tissue  into  the  space  between  the  ends  of  the  tendon ;  the  space 
is  thus  filled  up ;  as  in  any  wound,  tliis  tissue  is  infiltrated  with  plas- 
tic matter  and  serum,  and  becomes  very  vascular ;  the  cellular  tissue 
around  the  ends  of  the  tendon  is  metamorphosed  in  the  same  way,  and 
the  latter  are  surrounded  and  united  by  the  inflammatory  new  formation 
developed  from  the  adjacent  cellular  tissue,  just  as  the  fragments 
of  bone  are  by  the  external  callus  (which,  however,  here  presses 
41 


G2G 


CONGENITAL   DEFORMITIES   OF   THE   JOINTS,   ETC. 


between  the  ends  of  the  tendons  also ;    an  interna! 
Fig.  112.  callus  cannot  develop  in  tendons,  as  they  have  no 

medullary  cavit}').     In  this  stage  (about  the  fourth 
day),  the  picture  is  somevrhat  as  in  Fig.  113. 

This  provisional  union  soon  becomes  firm,  as  the 
inflammatory  new  formation  is  metamorphosed  to 
connective  tissue ;  meantime,  some  neoplastic  tissue 
has  developed  in  the  stumps  of  the  tendon,  which 
combines  vrith  the  intermediate  substance.  The 
entire  newly-formed  intermediate  mass  gradually 
contracts  strongly,  becomes  very  firm,  so  that  it  as- 
sumes exactly  the  character  of  tendinous  tissue ;  the 
tendon  is  thus  entirely  regenerated.  It  is  true  this 
does  not  always  go  on  as  rapidly  as  we  have  here 
described,  but  (as  also  occurs  in  fractures)  is  not 
unfrequently  interfered  with  by  a  large  extravasa- 
tion of  blood  between  the  ends  of  the  tendon  ;  this 
is  enclosed  by  the  inflammatory  new  formation,  be- 
comes only  partially  organized,  but  must  be  mostly 
reabsorbed  before  there  can  be  complete  regenera- 
I)  agrain  of  a  Piibcuta-  ^Jq^  ^f  ^jjg  tendon.    Extensive  extravasations  of  blood 

ueouisly-divicled  ten- 
don, on  the  fourth  may  interfere  with  the  regular  course  of  healing, 

not  only  by  their  size  and  the  time  required  for  their 
absorption,  but  by  occasionally  putrefying  and  suppurating.  The  oper- 
ation and  course  of  healing  in  myotomy  are  about  the  same  as  have 
just  been  described. 

You  have  just  heard  that  the  tendon  is  entirely  regenerated,  and 
the  cicatricial  intermediate  substance  contracts  strongly,  that  is,  it 
shortens,  and  you  will  justly  wonder  why,  knowing  these  facts,  the 
operation  is  still  done,  as  the  tendon  is  not  thereby  much  elongated. 
To  this  I  answer  that  tenotomy  of  itself  is  of  no  use,  or,  at  least,  does 
little  good,  but  that  the  tendinous  cicatrix  may  be  much  more  readily 
stretched  than  the  tendon  of  the  contracted  muscle  or  the  muscle  it- 
self; tenotomy  only  proves  useful  from  the  orthopedic  after-treatment ; 
it  greatly  aids  the  cure,  and  often  it  alone  renders  it  possible,  when 
the  contracted  muscles,  fascite,  or  ligaments,  resist  all  efforts  at  exten- 
sion. Hence  we  should  not  await  complete  cicatricial  contraction  of 
the  divided  tendon,  but  must  stretch  the  young  cicatrix ;  the  orthope- 
dic treatment  may  begin  ten  or  twelve  days  after  division  of  the  ten- 
don in  club-foot,  either  by  extension,  manipulations,  and  apparatus,  or 
by  straightening  the  foot  and  applying  a  plaster  dressing.  Favorable 
results  were  first  rendered  possible  by  subcutaneous  tenotomy ;  then 
the  healing  goes  on  rapidly,  and  a  distensible  cicatrix  forms ;  if  the 


TENOTOMY.  627 

wound  suppurates  a  long  time,  and  the  skin  is  also  affected,  the  bnttle 
cicatrix  probably  may  not  become  distensible  for  six  or  eight  weeks 
for  sooner  it  might  tear  and  begin  to  suppurate  again.     Of  course 
every  club-foot,  especially  of  the  lower  grades,  does  not  require  tenot- 
omy ;  but  it  is  just  as  certain  that  in  high  grades  of  this  deformity 
tenotomy  favors  the  cure.     From  what  has  been  said,  you  will  see 
that  the  indications  for  tenotomy  are  often  the  same  as  those  for 
orthopedic  treatment ;  this  is  not  absolutely  the  case  ;  the  indications 
for  tenotomy  are  sometimes  more  limited,  sometimes  more  general. 
We  may  divide  any  tense  tendon  subcutaneously ;   but  whether  this 
will  do  any  good  is  another  question.    We  cannot  here  speak  of  all 
possible  cases,  but  I  will  mention  the  tendons  most  frequently  divided : 
in  the  neck,  the  two  portions  of  the  sterno-cleido-mastoid  muscle,  at 
their  insertions  on  the  clavicle  and  sternum  ;  tenotomy  is  rarely  done 
in  the  arm  ;  I  warn  you  against  this  operation  in  the  fingers  and  toes ; 
all  tendons  with  fully-developed  sheaths  are  unsuited  for  tenotomy  • 
from  anatomical  reasons,  that  you  may  readily  perceive,  healing  would 
not  occur  so  simply  as  in  tendons  surrounded  by  loose  cellular  tissue  ; 
there  is  usually  suppuration,  frequently  with  bad  results,  or  else  the 
ends  of  the  tendon  remain  ununited.     In  the  thigh,  after  coxitis,  the 
contracted  adductor  muscle  may  be  divided  at  its  point  of  origin,  if 
its  contraction  cannot  be  overcome  during  anaesthesia ;  the  same  is 
true   of  the  biceps  femoris,  semitendinosus   and  semimembranosus, 
which  are  to  be  divided  close  to  their  points  of  insertion  into  the 
fibula  and  tibia.     In  the  foot,  the  tendo  Achillis  is  most  frequently 
divided,  as  are  also  occasionally  the  tendons  of  the  anterior  and  poste- 
rior tibial  and  peroneal  muscles,  although  it  seems  to  me  that  this 
injures  the  subsequent  mobility  of  the  foot.     In  straightening  anchy- 
loses, tenotomy  was  formerly  very  often  resorted  to  ;  but  for  this  pur- 
pose it  may  be  entirely  dispensed  with.     In  anchylosis  of  tlie  knee- 
joint,  for  instance,  if  the  above-named  muscles  be  not  united  to  a  cic- 
atrix, they  may  be  gradually  stretched  during  anaesthesia,  that  is,  if 
they  be  still  muscles  and  not  strings  of  pure  connective  tissue,  as  is 
rarely  the  case.     I  shall  not  here   speak  of  tenotomy  of  the  ocular 
muscles,  the  operation  of  strabismus,  as  this  is  treated  of  in  ophthal- 
mology.    Sometimes,  also,  we  may  be  obliged  to  divide   tendons  in 
antagonistic  contractions,  for  the  purpose  of  rendering  the  contracted 
muscles  inactive  for  a  time,  and  subsequently  elongating  their  tendon,-; 
by  extension,  to  give  the  paretic  antagonist  more  play  and  less  work  ; 
the  latter  are  then  opposed  by  no  force,  or,  at  least,  by  a  weaker  one 
so  that  equilibrium  is  restored.     Of  course,  this  is  only  to  be  done 
for  muscles  whose  antagonists  are  not  entirely  paralyzed,  but  only 
paretic;    in  perfect   paralysis,  tenotomy  of  the  contracted  muscles 


628  CONGENITAL   DEFORMITIES   OF   THE   JOINTS,   ETC. 

would  have  no  eiFect.  The  revivifymg  action  of  tenotomy  is  occasion- 
ally spoken  of;  it  is  to  the  above  cases  that  this  expression  refers; 
indeed  in  antagonistic  contractions  the  action  of  tenotomy  is  some- 
times astonishing. 

The  subcutaneous  division  of fascian  is  not  much  done;  the  cords 
of  the  fascia  lata,  which  form  when  the  thigh  is  kept  flexed,  are  often 
divided  with  benefit,  as  it  is  difficult  to  stretch  them ;  the  fascia  plan- 
taris  may  also  be  occasionally  divided  with  benefit,  when  it  is  tense, 
in  club-foot.  Division  of  the  fascia  fails  in  the  cases  where  we  might 
use  it  with  most  benefit,  that  is,  in  contraction  of  the  palmar  fascia. 
From  Dupuytre7i^s  description  of  the  results  of  this  operation,  in  spite 
of  the  warning  of  my  former  preceptor,  I  was  once  led  into  per- 
forming it ;  but  it  was  followed  by  such  extensive  suppuration  that  I 
was  glad  when  this  finally  ceased.  In  spite  of  all  orthopedic  after- 
treatment,  the  hand  finally  remained  as  it  had  been ;  some  shght  im- 
provement soon  disappeared  again,  and  I  believe  that  this  affection, 
in  its  higher  grades  at  least,  is  incurable. 

Division  of  ligaments  is  rare;  but  in  club-foot  I  have  often  divided 
the  small  ligaments  of  the  ankle-bones,  if  they  were  tense ;  and,  in 
spite  of  the  fact  that  I  must  certainly  have  frequently  opened  the 
small  joints  subcutaneously  in  so  doing,  I  never  saw  any  bad  results. 
B.  von  LangenhecTc  introduced  division  of  the  external  lateral  ligament 
of  the  knee  in  genu  valgum ;  in  this  the  knee-joint  is  always  tempo- 
rarily opened.  This  operation  is  only  proper  in  the  highest  grade  of 
the  affection,  but  greatly  aids  the  treatment ;  I  had  not  previously 
seen  it,  or  even  thought  much  about  it,  fearing  that  it  might  be  fol- 
lowed by  suppuration  of  the  knee-joint ;  a  few  years  since,  in  one 
case,  I  did  the  operation  on  both  knees  of  a  young  man  who  had  ex- 
cessive genu  valgum ;  the  wound  healed  without  any  inflammation  of 
the  knee-joint,  and  the  orthopedic  treatment  was  very  quickly  con- 
cluded. The  patient  went  out  of  the  hospital  with  his  legs  perfectly 
straight.  On  the  whole,  the  operation  is  rarely  indicated.  So  far  as 
I  know,  no  other  ligaments  are  divided. 

It  was  natural  to  think  of  dividing  contracting  cicatrices  also,  so 
as  to  stretch  the  new  cicatrix ;  but  would  it  not  be  vviser  not  to  let 
the  cicatricial  contraction  come  to  such  a  point  as  to  impair  function  ? 
Would  it  not  be  best,  even  during  the  healing  of  a  large  wound — in 
the  bend  of  the  elbow,  for  instance — to  keep  the  arm  extended,  so 
that  it  should  not  be  contracted  by  the  cicatrix  ?  The  idea  is  a  good 
one ;  "but  the  result  rarely  corresponds  to  such  a  tedious  treatment, 
for,  in  the  first  place,  such  wounds,  in  which  there  can  be  no  cicatricial 
contraction,  heal  with  great  difficulty,  and,  when  they  are  finally  healed 
and  the  limb  is  set  free,  contraction  nevertheless  occurs.     I  well  re 


CONTRACTED  MUSCLES.  629 

member  a  child  with  such  a  wound  in  the  bend  of  the  elbow,  from  a 
burn,  which,  as  assistant  in  the  Berlin  chnic,  I  had  to  dress  daily.  The 
arm  was  kept  extended  on  a  splint,  and  took  six  months  to  heal ; 
finally,  the  child  was  discharged,  with  the  arm  perfectly  movable  and 
the  wound  healed,  and  I  was  very  provid  of  the  cure.  Two  months 
later  I  saw  the  child,  with  the  cicatrix  entirely  contracted  ;  the  arm 
was  at  an  acute  angle,  and  almost  immovable.  Subsequently  I  lost 
sight  of  the  patient,  and  do  not  know  what  was  the  final  result ;  but 
I  clearly  saw  that  I  had  worried  myself  and  the  child  for  months  in 
vain.  Several  similar  cases  have  radically  cured  me  of  the  idea  that 
we  can,  in  such  cases,  do  much  by  orthopedic  treatment  during  the 
cicatrization  of  the  wound.  I  advise  you  to  let  the  wounds  heal  as 
they  will ;  large  wounds,  from  burns  in  children,  will  even  thus  give 
you  enough  trouble,  as  they  alwaj^s  heal  with  difficulty,  and  readily 
assume  an  ulcerative  character.  In  the  course  of  months,  often  not 
for  years,  as  its  vessels  are  obliterated  and  its  tissue  becomes  more 
like  subcutaneous  tissue,  the  cicatrix  loses  its  rigidity,  becomes  more 
distensible,  tougher,  more  elastic;  hence,  with  time,  mobility  in- 
creases, in  case  it  has  been  impaired  by  the  cicatrix.  You  have  al- 
ready been  told  how  you  may  aid  this  atrophy  of  the  cicatrix  by  com- 
pression and  distention.  When  the  cicatrix  has  finally  been  reduced 
to  the  smallest  size,  you  may  occasionally,  with  advantage,  excise 
the  whole  or  part  of  it,  at  intervals,  always  being  careful  to  obtain 
healing  by  the  first  intention,  so  that,  in  place  of  the  thick,  scarcely- 
distensible  cicatricial  string,  you  may  have  a  fine  linear  cutaneous 
cicatrix,  which  may  be  stretched  more  readily  than  the  old  cicatrix ; 
but  if  you  have  suppuration  and  gaping  of  the  wound  after  these 
operations,  the  result  is  very  doubtful  (as,  under  the  same  circum- 
stances, in  tenotomy) ;  there  again  forms  a  broad,  granulating,  slowly- 
healing  wound,  and  a  cicatrix  as  broad,  long,  and  firm  as  the  previous 
one.  Hence  you  can  only  advantageously  excise  contracted,  string- 
like, thin  cicatrices.  In  removing  complete,  broad  cicatrices,  such  as 
occur  in  the  neck  after  burns,  excision  is  not  enough ;  a  portion  of 
distensible  skin  from  the  vicinity  must  be  made  to  grow  in  the  place 
of  the  cicatrix.  This  may  be  done  by  sliding  a  piece  of  neighboring 
skin,  or  by  transplanting  a  flap  of  skin,  according  to  the  rules  of  plas- 
tic surgery,  which  I  shall  not  enter  into  here. 

We  have  now  to  speak  of  the  treatment  of  distortions  due  to  an- 
lagonistic  muscular  contractions ;  I  have  already  told  you  that  tenot- 
omy may  be  useful  in  these  cases  also,  but  it  is  only  an  adjuvant  to 
the  treatment;  the  essential  point  is  the  removal  of  the  paralysis. 
The  curability  of  these  contractions,  and  of  the  deformities  they  cause, 
will  depend  on  what  we  can  do  for  the  paralysis.     Here  opens  the 


630  CONGENITAL  DEFORMITIES   OF   THE   JOINTS,   ETC. 

wide  field  of  neuropathology,  -v^itli  -wliicli  jo\i  will  become  better  ac- 
quainted in  the  lectures  on  medicine,  and  in  the  medical  clinic.  There 
are  many  cases  where  you  would  at  the  outset  give  up  any  treatment  of 
the  paralysis ;  in  tumors  of  the  brain,  apoplexies,  chronic  encephalitis, 
traumatic  injuries  of  the  spinal  medulla,  extensive  injuries  of  nerves, 
etc.,  treatment  will  do  little  good.  Other  cases  of  spinal  disease  with 
paresis  of  the  lower  limbs,  especially  in  children,  sometimes  give  a 
relatively  good  prognosis.  On  the  one  hand,  treatment  with  cod-liver 
oil  and  hon,  malt  or  salt  baths,  and  especially  time,  may  act  very  ad- 
vantageously in  removing  the  changes  in  the  spinal  medulla,  of  which 
we  unfortunately  know  but  little ;  on  the  other  hand,  irritations  may 
be  applied  to  the  muscles  themselves,  that  may  revivify  them;  we 
may  expect  relief  in  those  cases  especially  where  there  is  no  complete 
paralysis  or  paraplegia,  but  only  paresis  of  certain  groups  of  muscles. 
Here  two  external  remedies  are  the  most  useful:  1.  Gymnastic  treat- 
ment /  2.  Electricity.  The  former  consists  in  awakening  the  slumber- 
ing, slightly-developed  contractile  power  by  concentrating  the  will  on 
the  paretic  muscles.  Certain  movements  are  made  regularly  at  cer- 
tain times ;  this  may  be  well  done  by  the  "  Swedish  movement-cure  " 
that  has  been  recently  introduced:  this  consists  in  requiring  the 
patient  to  make  movements  with  certain  muscles,  while  the  gymnast 
oflFers  a  slight  opposition.  For  instance,  I  hold  your  arm  extended; 
you  now  bend  it,  while  I  oppose  the  movement  by  gentle  pressure ;  of 
course,  the  proper  movements  must  be  determined  for  each  individual 
case.  Of  late,  this  method  of  gymnastics  has  become  quite  popular, 
and  proved  useful ;  evidently  it,  like  all  gymnastics,  is  useless  in  com- 
plete paralysis. 

Our  second  remedy  is  electricity;  of  late  great  advances  have  been 
made  in  its  use.  The  apparatus  employed  has  been  greatlj'  simplified, 
rendered  more  transportable,  and  so  adjusted  that  the  current  can  be 
strengthened  or  weakened  at  will.  Moreover,  the  methods  in  which  elec- 
tricity is  applied  are  greatly  improved  ;  formerly  one  or  several  groups 
of  muscles  of  a  limb  were  electiified,  by  applying  the  poles  first  on 
oi.e  place  then  another;  now  we  understand  electrifying  the  individual 
muscles ;  the  French  phj'sician  Duchenne  de  ^Boulogne  has  done  great 
service  in  this  matter.  The  points  at  which  the  pole  or  poles  should  be 
applied  to  induce  contractions  in  the  different  muscles  were  first  found 
empirically  by  Duchenne  j  subsequently  Remak  discovered  that,  as  a 
rule,  it  was  at  the  point  where  the  largest  motor  nerve  entered  the 
muscle.  Of  late,  Ziemssen  has  been  most  successful  in  electro-thera- 
peutics ;  his  book  is  characterized  by  practical  utility  and  scientific 
importance,  and  above  all  by  its  trustworthiness.  The  treatment  is 
BO  carried  out  that  usually  one  or  two  sittings  are  had  dailv,  during 


CONTRACTED  MUSCLES.  631 

which  fiist  one,  then  another,  muscle  is  methodically  electrified;  this 
may  be  continued  half  or  tliree-quarters  of  an  hour,  but  not  too  long, 
for  fear  of  destroying  the  weak  nervous  acti\'ity  by  too  great  irrita- 
tion. Much  harm  might  be  done  by  excessive  electrization ;  a  physi- 
cian should  always  conduct  the  treatment,  and  give  very  positive  di 
rections  about  the  duration  of  the  sitting,  and  strength  of  the  current. 
Usually  we  very  soon  see  how  much  the  muscles  contract  to  the  elec- 
trical irritation  when  they  perhaps  cannot  be  moved  spontaneously ; 
we  should  not  give  up  even  if  we  do  not  obtain  any  twitchings  at  the 
first  sitting ;  occasionally  these  only  appear  after  a  time,  when  the 
electricity  has  had  some  effect. 

Of  late,  JBaricell  has  successfully  employed  a  very  ingenious  meth- 
od for  removing  contractions;  he  makes  continued  traction  in  the 
direction  in  which  the  muscles  fail  to  act ;  for  instance,  in  club-foot,  a 
stout  india-rubber  band  is  fastened  to  the  outer  border  of  the  foot, 
and  the  inner  side  of  the  tibia  close  below  the  knee ;  this  acts  contin- 
uously as  an  "  artificial  muscle."  This  seems  to  me  rational,  and  it 
should  be  tried  extensively.  I  have  used  this  method  in  several  cases, 
with  very  quick  result ;  LUcke  and  Volkmann  have  also  stated 
recently  that  they  have  attained  good  results  by  this  treatment. 

In  pareses,  movement  of  a  fevv  muscles  occasionally  suflBces  to 
enable  the  patient  to  walk,  if  a  certain  firmness  which  the  muscles  fail 
to  supply  is  given  to  the  limb  l)y  some  sort  of  a  splint.  These  splints 
are  not  always  to  be  regarded  as  a  last  resort,  but  they  may  aid  the 
treatment  by  enabling  the  patient  to  walk  alone  with  the  aid  of  sticks. 
But  the  movements  of  walking,  made  by  the  paretic  muscles,  have  an 
excellent  gymnastic  effect;  although  artificially  supported,  the  patient 
in  this  way  uses  his  muscles,  while,  if  he  were  continually  lying  or  sit- 
ting, the  muscles  would  remain  entirely  inactive,  and  atrophy  more 
and  more.  Machines  are  also  serviceable  in  keeping  the  legs  ex- 
tended and  the  feet  at  the  proper  angle,  thus  preventing  contractions. 

Gymnastics,  electricity,  artificial  muscles,  and  splint  apparatuses, 
combined  with  proper '  internal  treatment,  especially  suitable  water- 
cure,  may  do  a  great  deal  for  these  patients  ;  and,  although  many  of 
them  are  incurable,  some  are  ciu-able,  and  others  may  be  greatly  im- 
proved. 

[The  hypothesis  of  siren  formation  advanced  (page  615)  is  sup- 
ported by  the  formation  of  the  seal,  so  many  of  the  stages  of  develop- 
ment of  the  human  embryo  correspond  to  what  we  find  persisting  in 
some  of  the  lower  animals.  Dieffenbach  had  noticed  that  all  new- 
born children  had  a  slight  degree  of  club-foot,  and,  as  a  fact,  the  rota- 
tion of  the  limbs  is  not  completed  at  birth,  nor  till  during  the  first 
year  of  life,  or  even  later,  when  the  child  begins  to  walk.     At  first 


632  CONGENITAL   DEFORMITIES   OF   THE   JOINTS,  ETC. 

the  toes  point  inward,  so  that  when  learning  to  walk  children  often 
QO  on  the  toes.  You  could  not  readily  place  a  six-months-old  child 
in  the  typical  position  of  the  soldier,  with  the  heels  together,  toes 
turned  out,  and  legs  touching  all  the  way  up.  As  the  rotation  does 
not  affect  the  foot  alone  but  the  entire  limb,  the  knee  and  hip  of 
the  newly-born  child  are  not  identical  with  those  of  adults,  and  this 
difference  is  even  more  marked  in  congenital  club-foot. 

An  important  factor  in  the  development  of  scoliosis,  in  addition 
to  those  mentioned  (page  618),  is  the  position  assumed  in  certain 
occupations,  as  in  writing,  etc.  If  the  school-benches  or  tables  be 
improperly  constructed,  the  body  may  be  kept  daily  for  hours  in 
an  unnatural  position.  The  longer  the  study-hours,  the  less  time 
given  to  recreation  and  exercise,  the  greater  the  effect  of  this  extra 
fatigue  ;  so  that  finally  the  faulty  position,  which  was  at  first  as- 
sumed merely  during  the  occupation,  becomes  habitual,  and  the 
spine  does  not  resume  its  normal  shape.  At  first  by  traction  the 
curvature  may  be  straightened  out,  or  the  children  may  do  it  volun- 
tarily, but  after  a  time  this  is  not  readily  accomplished. 

Quite  recently  Mikulicz  made  very  thorough  investigation  of 
the  statistics  of  genu  valgum,  which  proved  that  the  first  changes 
showed  in  the  diaphyses  of  the  femur  and  tibia,  and  that  the  de- 
formity was  due  partly  to  uneven  growth  at  the  epiphyses,  partly 
to  abnormal  curvature  of  the  diaphyseal  ends.  At  first  the  knee- 
joint  with  all  its  parts  are  not  implicated,  so  that  the  epiphyses 
appear  set  on  to  the  abnormally  curved  ends  of  the  diaphyses. 
Genu  valgum  is  always  accompanied  by  rachitis  of  the  limbs.  In 
high  grades,  besides  the  already  mentioned  anomalies  of  growth, 
there  is  irregular  proliferation  of  the  epiphyseal  cartilages,  the  inner 
one  increasing,  the  outer  diminishing,  and  thus  increasing  the  de- 
formity. Through  these  influences  combined,  the  height  of  the  in- 
ternal condyle  of  the  femur  is  increased,  while  the  external  condyle 
does  not  grow  ;  the  internal  lateral  ligament  elongates  while  the 
external  contracts  :  as  a  consequence,  the  biceps  muscle  shortens 
and  forms  a  tense  cord. 

Genu  valgum  is  always  accompanied  by  a  pathological  distortion 
of  the  foot ;  foi',  in  spite  of  the  angular  position  of  the  knee,  to 
bring  the  sole  of  the  foot  to  the  ground  the  patient  usually  treads 
on  the  outer  border  of  the  foot,  while  the  inner  is  elevated  ;  so  the 
metatarsus  is  twisted  on  its  long  axis,  as  in  pes  varus.  When 
patients  with  genu  valgus  have  been  able  by  this  manoeuvre  to  cor- 
rect the  anomaly  of  the  knee-joint,  their  gait  is  bearable  and  the 
inconvenience  comparatively  slight,  even  when  the  varus  is  consid 


CONTRACTED   MUSCLES.  633 

erable  ;  but  the  case  is  quite  different  in  patients  who  have  from 
the  first  walked  on  the  inner  border  of  the  foot ;  they  soon  acquire 
marked  pes  planus,  which  renders  walking  nearly  impossible.  Severe 
pains  occur  in  the  foot,  the  gait  becomes  tottering  and  painful,  and 
the  combination  of  genu  valgum  and  pes  valgus  not  unfrequently 
induces  the  greatest  functional  disturbances  of  the  lower  extremity. 
Even  slight  grades  of  pes  planus  greatly  impair  the  use  of  the  leg. 

Such  cases  are  very  frequent  in  young  children,  and  may  often 
be  remedied  by  inserting  a  piece  of  beveled  sole-leather  in  the  shoe 
under  the  instep. 

If  rigor  mortis  has  occurred  while  the  legs  were  lying  extended 
on  a  horizontal,  level  surface,  the  feet  are  always  fixed  in  a  position 
of  slight  equino-varus.  The  same  is  the  case  in  persons  who  have 
lain  long  in  bed  without  using  their  legs  ;  if  the  legs  be  not  moved, 
the  elevation  of  the  heel  and  rotation  of  the  foot  inward  constantly 
increase. 

After  injuries  or  inflammation  the  tendons  readily  become  ne- 
crosed, and  as  the  dead  tissue  is  only  replaced  by  cicatricial  sub- 
stance, the  tendon  is  shortened  and  the  cicatrix  is  united  with  the 
sheath,  which  destroys  the  natural  mobility  of  the  tendon.  Many 
such  cicatrices  in  muscles  are  congenital,  perhaps  caused  by  the 
umbilical  cord  encircling  a  limb.  Usually  this  amputates  the  limb, 
but  at  other  times  we  find  a  cicatricial  atrophy  of  the  skin  and  dis- 
appearance of  the  muscle,  which  we  must  suppose  to  be  replaced  by 
connective  tissue  ;  this  causes  shortening  of  the  muscle  and  distor- 
tions, particularly  in  the  foot.  Much  more  frequent  are  cases  of 
caput  obstipum  from  shortening  of  one  sternocleidomastoid  muscle 
from  acute  traumatic  myositis  ;  this  inflammation  is  probably  almost 
always  caused  by  injury  of  the  muscles  by  the  forceps  during  in- 
strumental delivery.  In  these  cases  immediately  after  birth,  and 
during  the  first  week  of  life,  we  may  find  an  extensive,  painful 
inflammatory  swelling  of  the  muscle,  which  disappears  spontane- 
ously, usually  leaving  cicatricial  shortening,  but  sometimes  going 
on  to  suppuration  and  formation  of  a  true  abscess  of  the  muscle, 
which  of  course  heals  with  a  shrinking  cicatrix.] 


CHAPTER  XIX. 

./J 

YAEICES  AND  AJSTJEUEISMS.  \ 


LECTURE   XLIII. 

Varices:  Various  Forms,  Causes,  Various  Localities  wliere  they  occur. — Diagnosis. — 
Vein-stones,  Varicose  Lymphatic  Vessels,  Lymphorrha?a. — Treatment. — Aneu- 
risms: Inflammation  of  Arteries. — Aneurysma  Cirsoidcum. — Atheroma. — Various 
Forms  of  Aneurism. — Their  Subsequent  Changes.— Symptoms,  Results,  Etiology, 
Diagnosis. — Treatment:  Compression,  Ligation,  Injection  of  Liquor  Ferri,  Extir- 
pation. 

By  varices  we  mean  distentions  of  veins ;  these  may  have  various 
forms,  and  usually  affect  both  the  diameter  and  length  of  the  vessel. 
Elongation  is  only  possible  when  the  vessel  bends  laterally,  and  takes 
a  tortuous  course,  as  also  occurs  in  inflammation  of  the  smaller  vessels. 
In  some  cases  the  elongation  is  less  marked,  and  the  diameter  of  the 
canal  is  not  regular,  but  the  vessel  is  distended  in  a  spindle  or  sack- 
like shape  at  different  points,  especially  where  the  valves  are.  Most 
frequently  the  large  veins  of  the  subcutaneous  cellular  tissue  are  thus 
affected;  sometimes  chiefly  the  deep  muscular  veins,  often  both  are 
alike  affected.  But  there  are  also  varicosities  in  the  smallest  veins  of 
the  cutis,  which  are  scarcely  visible  to  the  naked  eye,  these  are  often 
the  only  ones  affected ;  this  gives  an  even,  light-blue  nodular  appear- 
ance to  the  skin.  As  a  result  of  this  distention  of  the  veins,  which 
occurs  very  gradually,  more  serum  than  usual  escapes  from  the  capil- 
lary vessels,  as  the  lateral  pressure  in  them  is  greatly  increased  by 
the  distention  of  the  walls  of  the  veins,  and  the  consequent  insuffi- 
ciency of  the  valves.  The  thinning  of  the  walls  of  the  vessels,  and 
the  transuded  excess  of  nutrient  material,  may  be  gradually  followed 
by  escape  of  wandering  cells,  and  their  organization  to  new  tissue ; 
thus  we  have  a  serous,  then  ceUular  infiltration,  and  thickening  of  the 
tissue  traversed  by  the  varices;  red  blood-cells  may  also  escape 
through  the  capillary  walls  (Cohnheim),    We  have  already  explained 


VARICOSE   VEINS. 


635 


Fig.  113. 


(Lecture  XXIX.)  how,  by  a  further  advance  of  this  process,  the  tissue 
is  more  and  more  changed,  and  chronic  inflammation  and  ulceration  in- 
duced.    In  this  way  are  developed  not  only  ulcer- 
ations but  also  some  other  forms  of  chronic  cuta- 
neous inflammations,  especially  a  chronic  eruption 
of  vesicles,  "  eczema  "  of  the  leg. 

Now  we  must  take  up  the  question,  What  is 
the  cause  of  varices?  It  is  probable  that  the 
cause  is  an  obstruction  to  the  return  of  the  venous 
blood,  a  pressure,  compression,  or  naiTowing  of 
the  calibre  of  the  vessel  in  some  way.  But  the 
obstruction  cannot  be  of  sudden  origin,  for  this 
usually  causes  oedema ;  the  same  is  true  of  liga- 
tion of  a  large  venous  trunk  and  rapidly-appear- 
ing thromboses.  The  pressure  must  then  aflect 
the  vein  gradually.  Still,  even  this  is  not  enough ; 
often  a  gradually-increasing  pressure  does  not 
cause  varicose  veins,  but  free  collateral  modes  of 
escape  form,  so  tliat  there  is  no  effect,  or  only  a 
slight,  indurated  oedema.  There  must  be  a  coin- 
cident tendency  to  dilatation  of  the  vessels,  a  cer- 
tain laxity  or  distensibility  of  the  walls  of  the 
veins. 

Anatomical  examination  of  varicose  veins 
shows  that  the  walls  are  absolutely  thickened  by 
deposits  of  connective  tissue  between  the  muscle- 
cells,  but  the  latter  do  not  seem  increased,  and,  as 
the  calibre  of  the  vessel  is  six  or  eight  times  the  normal  size,  they  must 
prove  insufficient  to  urge  the  blood  onward,  the  more  so  as  the  valves 
do  not  grow  as  the  dilatation  goes  on,  and  consequently  soon  prove  in- 
Bufiicient.  Up  to  the  present  time  we  have  had  no  detailed  histological 
investigations  about  the  formation  of  varices,  and  especially  about 
the  relation  of  this  disease  to  aneurism.  In  many  cases  the  dispo- 
sition to  varices  may  be  regarded  as  individual,  in  others  it  is  in- 
herited ;  diseases  of  the  vessels  are  not  unfrequently  hereditary,  those 
of  the  arteries,  as  well  as  of  the  veins  and  of  the  capillaries,  by  whose 
morbid  dilatation  the  so-called  mother's  marks  are  caused,  whose 
transmission  by  inheritance  is  known  even  to  the  laity.  Hence,  we 
can  only  regard  the  cause  of  varices,  which  we  are  about  to  mention, 
as  exciting  causes  acting  on  an  existing  predisposition.  The  disease 
is  more  frequent  in  women  than  in  men  ;  the  chief  cause  is  said  to  be 
repeated  pregnancies  :  the  uterus,  gradually  enlarging,  presses  on  the 
common  iliac  veins,  and  later  on  the  vena  cava,  and  occasionally  this 


Varices  in  the  part  sup- 
plied by  the  great  sa- 
phena  vein. 


636  VARICES   AND   ANEURISMS. 

even  induces  oedema  of  the  feet.  Often  there  are  varices  in  all  the 
parts  supplied  by  the  saphenous  vein  ;  again,  in  those  supplied  by  the 
pudic,  as  in  the  labia  majora.  It  is  far  more  difficult  to  find  the  causes 
of  the  more  rarely-occurring  varices  in  man.  Large  collections  of 
faeces  may,  by  pressure  on  the  abdominal  veins,  prove  an  exciting 
cause  of  varices,  but  this  is  rarely  seen.  In  many  men  with  varices 
you  will  find  disproportionately  long  lower  limbs,  especially  long  be- 
low the  knee  ;  in  some  cases  this  may  also  favor  congestions  in  the 
veins.  Possibly,  also,  the  collection  of  hard  fat,  or  else  shrinkage  in 
the  falciform  process  of  the  fascia  lata,  may  cause  congestion  in  the 
saphenous  vein,  as  the  latter  sinks  into  the  femoral  at  this  point.  So 
far  as  I  know,  there  are  no  anatomical  investigations  on  this  point. 
The  obstruction  to  the  flow  of  blood  need  not  always  be  directly  in 
the  territory  of  the  dilated  veins :  for  instance,  gradual  narrowing  and 
final  obliteration  of  the  femoral  vein,  below  the  opening  of  the  sa- 
phena,  might  very  readily  cause  enormous  distention  of  the  branches  of 
the  latter  by  collateral  circulation.  Varices  occur  at  some  other  parts 
of  the  body,  especially  at  the  lower  part  of  the  rectum  and  in  the 
spermatic  cord.  Varices  of  the  hjemorrhoidal  veins  in  the  lower  part 
of  the  rectum  cause  haemorrhoids,  which,  as  is  well  known,  occur 
chiefly  among  persons  who  lead  a  sedentary  life.  The  disease  is  very 
rare  in  other  parts  of  the  body ;  it  occasionally  occurs  in  the  head, 
usually  without  known  cause,  it  may  form  after  an  injury,  if  this  be 
followed  by  union  of  the  walls  of  the  arteries  and  veins  and  passage 
of  arterial  blood  into  the  veins ;  this  would  be  a  varix  aneurysmaticus, 
of  which  we  spoke  in  the  second  chapter.  In  the  pathological  ana- 
tomical atlas  of  Cruveilhier  you  find  given  as  a  great  rarity  a  picture 
of  large  varices  of  the  abdominal  veins  ;  there  is  a  similar  preparation 
in  the  pathological  museum  at  Vienna. 

The  diagnosis  of  varices  is  not  difficult  when  the  cutaneous  veins 
are  affected  ;  those  of  the  deep  muscular  veins  can  rarely  be  diag- 
nosed with  certainty  ;  in  the  leg  and  thigh  the  whole  course  of  the 
tortuous  veins  is  so  evident  through  the  skin  that  they  may  be  readily 
recognized,  but  in  other  cases  we  see  only  a  few  light-bkie,  fluctuat- 
ing, compressible  nodules;  these  chiefly  correspond  to  the  sac-like 
dilatations  of  the  veins,  and  to  the  points  where  the  valves  are.  Here 
we  occasionally  find  hard,  round  bodies,  phlebolites  or  vein-stones  ;  on 
examination,  these  prove  to  be  nodules  in  layers,  at  first  consisting 
of  fibrine  ;  they  may  subsequently  calcifj'  entirely,  so  as  to  assume  the 
appearance  of  small  peas.  In  the  great  majority  of  cases,  varices  of 
the  lower  extremities  cause  no  difficulty,  except,  perhaps,  a  feeling 
of  tension  and  heaviness  in  the  limbs  after  long  standing  or  walking. 
But  in  other  cases  there  are  occasionally  thrombi  in  single  venous  dila 


TREATMENT   OF  VARICES.  637 

tat  ions  ;  inflammation  of  the  wall  of  the  vein  and  surrounding  cellular 
tissue  follows,  and,  although,  under  early  treatment,  the  inflammation 
usually  terminates  in  resolution,  suppuration  or  abscess  may  eventu- 
ally develop.  The  treatment  is  the  same  as  has  been  already  given 
for  traumatic  thrombus  and  phlebitis.  Another  danger  that  may 
arise  from  varix  is  its  rupture,  a  very  rare  occurrence ;  if  the  patient 
be  kept  quiet,  the  bleeding  may  be  readily  checked  by  compression, 
and  there  is  no  danger  if  medical  aid  be  at  hand.  A  varicose  ulcer, 
in  the  strict  meaning,  may  form  from  such  a  ruptured  varix,  but  this 
is  rare,  for  the  wound  usually  heals  quickly.  If  the  skin  and  subcu- 
taneous tissue  of  the  leg  be  greatly  indurated,  and  if  this  induration 
has  also  affected  the  adventitia  of  the  cutaneous  veins,  they  lie  im- 
movable, and,  in  the  firm,  leathery,  rigid  skin,  they  feel  like  half  canals 
or  gutters.  I  call  your  attention  to  this,  as  otherwise  in  such  cases, 
from  the  induration  of  the  skin,  you  might  entirely  overlook  the  varices. 
The  treatment  of  varices  is  very  unsatisfactory,  as  we  know  no 
way  of  removing  the  disposition  to  this  disease  of  the  veins.  Nor 
can  we  usually  control  the  causes  of  the  pressure;  so  we  may  really 
conclude  that  varices  are  not  curable,  i.  e.,  we  have  no  remedy  for 
restoring  the  morbidly-dilated  veins  to  their  normal  size.  For  some 
cases  we  must  say  that,  physiologically  considered,  the  formation  of 
varices  is  Nature's  mode  of  equahzing  abnormal  pressure  in  the  ves- 
sels, and  that  we  may  not  try  to  remove  the  varices  till  we  can  get 
rid  of  their  causes,  for,  if  we  removed  one  or  more  of  these  morbid 
strings,  others  would  form  in  their  place.  For  this  reason  I  reject  all 
operations  which  aim  at  removing  one  or  more  varicose  nodules  from 
the  leg.  If  you  bear  in  mind  that  any  operation  on  the  veins  may 
prove  dangerous  to  life  by  comphcation  with  thrombosis  or  embolism, 
you  will  agree  Avith  me  in  considering  the  operation  for  varices  en- 
tirely uncalled  for.  Nevertheless,  these  operations  are  often  done  in 
France,  and  not  unfrequently  prove  fatal ;  there  are  many  methods 
of  operation,  about  which  we  shall  say  a  few  words.  The  oldest 
method,  which  was  practised  by  the  Greeks,  consists  in  exposing  the 
varicose  veins,  and  either  cutting  or  tearing  them  out.  Later,  the  hot 
iron  was  applied  to  induce  coagulation  of  blood  in  the  veins,  which 
resulted  in  obliteration  of  the  vessels.  We  may  also  inject  liquor 
ferri  sesquichlorati  wath  a  small  syringe  having  a  needle-shaped  noz- 
zle, as  you  know  this  quickly  causes  coagulation  of  the  blood.  After 
this  came  the  ligatiu-e  of  the  veins,  especially  the  subcutaneous  liga- 
ture after  Micord,  and  the  subcutaneous  rolling-up,  the  enroulement 
of  Vidal^  little  operations  that  I  shall  show  you  in  the  course  on  op- 
erations ;  these  are  very  ingenious  methods,  but  I  am  sorry  to  saj 
they  do  not  succeed,  and  are  not  free  from  danger. 


638  VARICES  AND  ANEURISMS. 

But  shall  we  do  notliing  for  varices?  Yes,  we  should  try  to  keep 
them  within  certain  bounds,  and  thus  prevent  or  reduce  to  a  niinimum 
their  bad  effects.  For  this  purpose  there  is  only  one  remedy,  con- 
tinued comi^ression^  which,  however,  must  only  be  used  in  such  a  de- 
gree as  is  bearable  to  the  patient.  We  use  two  different  mechanical 
modes  of  compression  in  these  cases,  the  laced  stocking  and  regular 
bandaging.  The  laced  stocking  consists  either  of  a  carefully-made, 
close-fitting  leather  stocking,  split  at  one  side,  and  laced  up,  like  cor- 
sets, till  it  is  tight  enough,  or  else  of  a  tissue  of  rubber  thread,  spun 
over  with  silk  or  cotton,  of  the  same  stuff  that  most  suspenders  are 
made  of.  These  laced  stockings,  which  must  be  very  carefully  made, 
and  worn  continually,  are  unfortunately  quite  expensive,  and,  as  they 
cannot  be  washed,  must  often  be  replaced,  so  that  they  are  only  prac- 
tically useful  for  persons  of  means.  In  most  cases  a  carefully-applied 
roller-bandage  suffices.  For  this  purpose,  you  may  best  take  a  cotton 
bandage  tAvo  or  three  fingers'  breadths  wide,  soaked  in  good  book- 
binder's paste,  and,  excepting  the  heel,  bandage  the  whole  foot  and 
leg ;  with  care,  such  a  bandage  may  be  worn  five  or  six  weeks,  and 
even  if  the  skin  be  considerably  infiltrated,  it  may  prevent  the  forma- 
tion of  ulcers  by  obstructing  the  further  development  of  varices. 


It  is  some  time  since  we  spoke  of  traumatic  aneurism^  but  you 
will  remember  that  we  mentioned  it  under  punctured  wounds  (page 
143),  and  that  I  then  told  you  an  aneurism  was  a  cavity,  a  sac,  which 
directly  or  indirectly  communicated  with  an  artery ;  you  already  know 
that  such  sacs  may  develop  from  injuries  of  the  artery  by  puncture, 
subcutaneous  rupture,  or  contusion.  But  now  we  do  not  mean  to 
speak  of  these  traumatic,  so-called  false  aneurisms,  but  of  aneurysma 
verum,  which  develops  gradually  from  disease  of  the  wall  of  the  ar- 
tery. To  explain  to  j^ou  clearly  how  this  occurs,  it  will  be  best  to 
start  from  the  anatomical  conditions.  At  present,  you  know  but  little 
of  the  diseases  of  arteries  ;  the  only  ones  that  have  been  mentioned 
so  far  are  thrombosis  after  injur}',  the  development  of  collateral  circu- 
lation, and  atheroma,  which  we  hastily  spoke  of  when  treating  of 
senile  gangrene.  And  these  comprise  almost  the  whole  list,  only  that 
so  far  we  have  taken  merely  a  one-sided  view  of  atheromatous  dis- 
ease. Of  the  different  parts  of  arteries  the  tunica  muscularis  and 
intima  are  most  frequently  diseased,  and  they  seem  to  be  affected 
primarily.  Tlie  tunica  media  is  composed  of  muscle-cells  ana  some 
connective  tissue;  the  tunica  intima  consists  of  non-vascular,  elastic 
lamellae,  fenestrated  membranes,  and  very  thin  endothelium.  It  may 
be  readily  shown  that,  after  injury  of  an   artery,  its  walls  swell,  and 


CIRSOID  ANEURISMS.  639 

remain  thickened  for  a  time ;  the  plastic  infiltration  of  the  walls  may 
lead  to  suppuration,  and  small  foci  of  matter  may  form  in  them, 
though  this  is  seen  more  rarely  in  arteries  than  in  veins.  With  these 
processes  there  is  a  relaxation  of  the  membranes,  the  intima  may  be 
detached  from  the  media  more  readily  than  usual,  the  latter  is  soft- 
ened, the  muscle-cells  may  in  part  disintegrate,  and,  as  a  result  of 
this  diminished  resistance,  there  may  be  a  dilatation  of  the  artery. 
Such  acute  inflammations  with  plastic  new  formations  and  partial 
softening  may  doubtless  occur  spontaneously,  and,  although  we  have 
no  special  observations  on  this  point,  still,  from  analogy  with  other 
tissues,  there  is  no  doubt  that  a  spontaneous,  idiopathic,  acute,  and 
subacute  inflammation  of  the  arteries  may  run  its  course  in  this  way, 
and  probably  occurs  with  acute  inflammations  of  other  tissues.  At 
all  events,  these  acute  spontaneous  inflammations  of  arteries  are  very 
rare ;  the  chronic  forms  are  far  more  frequent.  One  form  of  aneu- 
rism alone  possibly  depends  on  a  more  subacute  inflammation  of  the 
artery,  with  diminished  resistance  of  its  walls  ;  this  is  mieurysma 
cirsoideum,  or  aneurysma  per  anastomosing  also  called  aneurysma 
racemosuni.  Tliis  form  of  arterial  dilatation  is  totally  distinct 
from  the  aneurisms  to  be  hereafter  mentioned ;  in  them  there  is  not 
circumscribed  dilatation  of  one  part  of  an  artery,  but  dilatation  of  a 
large  number  of  arteries  lying  close  together,  which  are,  moreover, 
very  tortuous,  a  sign  that  they  have  also  increased  in  length.  Cirsoid 
aneurism  is,  then,  a  convolution  of  dilated  and  elongated  arteries. 
For  these  changes  to  occur,  there  must  be  a  considerable  new  forma- 
tion in  the  wall  of  the  artery,  longitudinallj'^,  as  well  as  in  the  circum- 
ference ;  the  dilatation  is  possibly  due  to  atrophy  of  the  muscular 
coat ;  usually  (without,  however,  being  able  to  prove  it)  paralysis  of 
the  walls  of  the  arteries  is  assumed  to  be  the  exciting  cause  of  this 
variety  of  aneurism  ;  still,  although  paralysis  might  explain  a  mod- 
erate dilatation  of  the  artery,  we  have  nothing  to  explain  the  paral- 
ysis, and  this  would  not  render  any  more  comprehensible  the  elonga- 
tion of  the  artery,  which  can  only  depend  on  a  new  formation  of  the 
elements  of  the  wall.  As  already  stated,  I  think  that  this  variety  of 
arterial  dilatation,  which  closely  resembles  inflammatory  dilatation 
and  looping  of  vessels,  must  be  referred  to  an  inflammatory  change 
in  the  artery,  and  not  to  chronic  inflammation  with  atheroma,  to  be 
hereafter  described,  but  to  a  more  subacute,  diff'use  inflammation. 
This  view  is  supported  by  various  etiological  factors  ;  these  aneu- 
risms not  unfrequently  develop  after  blows  or  other  injuries;  they  are 
most  frequent  at  points  where  numerous  small  arteries  anastomose,  as 
in  the  scalp,  over  the  occiput,  vertex,  and  temples ;  this  variety  of 
ineurism  might  be  regarded  as  an  excessively-developed  collateral 


640 


VARICES  AND  ANEURISMS. 


circulation ;  the  collateral  arteries,  besides  dilating,  become  tortuous ; 
the  process  is  evidently  the  same  in  both  cases.  We  have  also  to 
mention  that  these  aneurisms  are  particularly  apt  to  develop  in  yoimg 
persons,  in  whom  the  chronic  diseases  leading  to  other  aneurisms  are 


Fig.  114. 


Cirsoid  aneurism  of  the  scalp  in  an  old  woman  ;  a  small  tamor  was  said  to  have  existed  at 
birth,  and  to  have  developed  gradually  to  this  size.  After  Breschet. 


rare.  The  diagnosis  of  cirsoid  aneurism  is  very  simple,  if,  as  is  usu- 
ally the  case,  it  lies  just  under  the  skin ;  it  has  been  found  more 
deeply  seated,  as  in  the  gluteal  artery,  but  it  is  more  frequent  on  the 
head ;  here  we  may  feel,  and  occasionally  see,  the  tortuous  pulsating 
artery,  so  that  the  disease  is  readily  recognized ;  it  is  not  frequent. 

We  have  still  to  mention  that  the  arterial  wall  may  become  dis- 
eased by  a  suppuration  or  ulceration  extending  from  the  neighboring 
parts,  first  to  the  adventitia,  then  to  the  other  coats ;  this  is  the  case 
more  rarely  in  acute  abscesses  than  in  chronic  ulcerations.  As  an 
example  of  this  we  see  that,  in  the  development  of  cavities  in  the 
lungs,  it  not  unfrequently  happens  that  the  ulceration  attacks  the  walls 
of  the  smaller  arteries,  and  the  adventitia  is  partly  destroyed  and 
softened.     The  result  of  this  is,  that  the  artery  dilates  at  this  point. 


ATHEROMA   OF  THE   ARTERIES.  641 

and  a  small  aneurism  is  formed,  whose  rupture  causes  severe  lisem- 
orrhage.  Other  ulcerations  also  may  (though  this  rarely  happens)  find 
their  way  to  an  artery  and  destroy  its  walls,  so  as  to  induce  burstinj; 
of  the  artery,  and  fatal  hemorrhage  if  the  artery  be  a  large  one.  1 
have  seen  several  such  cases :  an  old  man  had  an  abscess  deep  in  the 
neck  which  opened  into  the  pharynx;  this  was  diagnosed  from  the 
gradual  formation  of  a  painful  swelling  in  the  neck  and  the  free  ex- 
pectoration of  badly -stnelling  pus ;  the  patient  had  only  been  in  the 
hospital  a  few  hours  Avhen  he  threw  tip  a  large  amount  of  blood,  was 
quickly  asi^hyxiated,  and  died ;  autopsy  showed  that,  as  a  result  of  cir- 
cumscribed suppuration  of  the  superior  thyroid  arterj^,  it  had  throAvn 
out  a  quantity  of  blood  which  had  passed  directly  into  the  larynx  and 
caused  suffocation.  In  another  case  in  a  young  man  who  had  caries 
of  the  right  temporal  bone,  there  were  repeated  haemorrhages  from  the 
right  ear ;  I  diagnosed  an  abscess  on  the  under  side  of  the  temporal 
bone  with  supiDuration  of  the  internal  carotid  artery.  The  bleeding 
could  not  be  checked  by  tamjDons  to  the  ear ;  I  ligated  the  right  com- 
mon carotid.  The  bleeding  ceased  for  ten  days,  then  began  again  ;  af- 
ter reiDeated  tamponading  and  digital  compression  of  the  left  carotid 
without  permanent  result,  I  also  ligated  the  left  common  carotid  ;  but 
in  two  days  the  patient  died  of  profuse  hcBmorrhage  from  the  right  ear, 
nose,  and  mouth ;  the  abscess,  which  was  filled  Avith  blood,  and  could 
now  be  regarded  as  an  aneurysma  spuriura,  had  also  opened  into  the 
pharynx.     The  2^ost  tnortem  fully  confirmed  the  diagnosis. 

We  now  come  to  chronic  diseases  of  the  arteries  and  their  results, 
to  true  aiietirisms.  In  advanced  age  it  is  very  common  for  the  arteries 
to  become  exceedingly  thick  and  hard  and  occasionally  even  looped, 
especially  those  of  the  diameter  of  the  radial  or  smaller.  If  we  ex- 
amine these  arteries  more  accurately,  we  find  the  tunica  intima 
thickened,  of  cartilaginous  firmness,  it  is  more  rigid  than  usual,  and 
gapes ;  in  places  it  is  even  as  hard  as  chalk,  or  even  quite  calcified  oi 
ossified.  The  chalky  parts  are  not  diffusely  spread  through  the  walls 
of  the  artery,  but  form  circles  corresponding  to  the  transverse  muscles 
of  the  tunica  media;  it  is  the  muscles  of  the  vessels  that  ossify. 
In  such  persons,  on  the  inner  surface  of  the  aorta  and  its  first  large 
branches,  we  find  whitish-yelloAV  spots,  stria?  or  plates  of  chalky  firm- 
ness, or  rough  as  if  gnawed,  with  their  edges  holloAved  out.  If  we 
cut  into  these  spots,  we  find  the  whole  intima  of  cai-tilaginous  hardness, 
whitish  yellow,  and  completely  calcareous  or  hard  as  bone,  or  else 
friable,  granular,  or  pulpy.  Where  this  disease  has  attained  a  high 
grade,  tlie  arteries  become  bulged  out.  This  is  atheroma  of  the  ar- 
tery as  it  appears  in  the  cadaver.  We  oft(^n  find  the  recent  and  old 
Stage  near  together  or  in  different  arteries.  If  we  examine  these  spots 
42 


642 


VARICES   AND   ANEURISMS. 


more  carefully  with  tbe  microscope,  especially  in  fine  cross  sections 
throiio-h  spots  of  different  appearance,  Ave  find  that  the  first  changes 
occur  in  the  outer  layers  of  the  intima,  on  the  holders  of  tlie  media ) 
here  a  moderate  groviping  of  cells  begins.  The  young  cells  may  lead 
to  connective  tissue  and  new  formation  and  callous  thickening  of  the 
arterial  w^all ;  but  they  are  usually  short-lived ;  while  new  ones  ap- 
pear in  the  periphery  of  the  aifected  spot,  the  first  ones  disintegrate 
to  a  granular  detritus,  to  a  pulp  formed  of  fine  molecules  and  fat, 
which  remains  rather  dry,  as  in  caseous  degeneration  ;  the  destruction 
thus  slowly  extends  laterally,  the  nutrition  of  the  media,  as  well  as 
of  the  inner  layers  of  the  intima,  suffers ;  the  muscle-cells  of  the  for- 
mer become  granular  and  fatty,  as  do  the  elastic  lamella?  of  the  in- 
tima ;  the  change  thus  progTCSses  inward  till  the  last  lamellae  and  the 
epithelial  membrane  are  perforated,  and  the  cavity  filled  with  ath- 
eromatous pulp  ojDens  into  the  calibre  of  the  artery.  The  atherom- 
atous process,  beginning  as  a  hollow  ulcer,  has  led  to  an  open  ulcer 
with  undermined  edges;  you  see  the  mechanism  is  the  same  that  you 
have  already  seen  in  the  skin  and  lymphatic  glands ;  there  is  a  chronic 
inflammation  ending  in  caseous  degeneration,  or,  as  the  pulp  is  called 
in  tliis  position,  in  atheroma.  This  is  the  essential  part  of  the  pro- 
cess, as  far  as  concerns  the  development  of  aneurism ;  but  there  are 
some  variations,  from  the  different  structures  of  the  arteries.  The 
less  developed  the  muscularis  and  intima,  the  less  atheromatous  pulp 
will  be  formed,  as  this  results  chiefly  from  breaking  down  of  the 
intima.  To  commence  with  the  small  arteries,  whose  diseases  we 
may  study  in  the  microscopic  cerebral  arteries :  here  we  find  the  col- 
lections of  cells  mostly  in  the  adventitia,  which  is  but  little  and  only 
secondarily  affected  in  large  arteries.  Almost  the  whole  adventitia 
changes  to  cells,  the  few  muscular  cells  atrophy,  the  fine  hyaline 
membrane,  which  acts  as  intima,  is  very  elastic  ;  thus  the  softening  of 
the  adventitia,  caused  by  the  cell-infiltration,  soon  induces  dilatation 
and  finally  bursting  of  the  artery,  as  the  walls  are  no  longer  suffi- 
ciently firm  to  resist  the  pressure  of  the  blood.  Occasionally  also 
there  is  a  plastic  production  of  adventitia ;  club-shaped  vegetations 
forai,  which  consist  partly  of  newly-formed  fibrous,  partly  mucous 
connective  tissue.  We  cannot  here  discuss  this  further,  especially  as 
it  does  not  affect  surgery.  A  fatty  degeneration  and  calcification  of 
the  muscular  coat  also  occur  along  with  the  plastic  infiltration  of  the 
adventitia  in  the  smaller  cerebral  arteries,  but  are  not  frequent.  Let 
us  pass  to  arteries  the  size  of  the  basilar,  radial,  etc.  Here  the  plas- 
tic process  in  the  adventitia  occasionally  still  combines  with  those  in 
the  other  coats,  although  pulpy  disintegration  and  calcification  of  the 
latter  do  occur.     Sometimes  there  are  thickening  and  looping  of  these 


ATHEROMA  OF   THE   ARTERIES.  643 

fti-leries,  sometimes  disintegration  and  softening,  with  consequent  dila- 
tation or  aneurism ;  for,  when  the  media  and  adventitia  become  soft- 
ened to  atheroma  pulp  at  some  point,  the  adventitia  is  no  longer 
strong  enough  to  resist  the  pressure  of  the  blood,  and  it  bulges.  If 
we  now  turn  to  the  large  arteries,  aorta,  carotid,  subclavian,  iliac,  and 
femoral,  in  Avhich,  you  know,  the  muscular  coat  is  reduced  to  a  mini- 
mum, or  is  even  occasionally  wanting,  while  the  intima  is  composed  of 
a  large  number  of  elastic  lamellie,  and  lies  almost  immediately  on  the 
adventitia,  which  has  more  or  less  elastic  filaments — here  there  is 
least  plastic  process  in  the  adventitia ;  the  pathological  change,  the 
disturbance  of  nutrition,  evinces  itself  chiefly  in  rapid  breaking  down 
or  calcification  of  the  pathological  new  formation,  which  occurs  partly 
on  the  borders  of  the  intima,  partly  in  that  coat.  As  already  men- 
tioned, cases  do  occur  where  extensive  circumscribed  connective-tissue 
new  formations  occur  in  the  intima  in  the  form  of  cartilaginous  callosi- 
ties ;  but  this  is  rarer  than  the  change  to  atheroma-pulp.  In  the  last 
mentioned  arteries  true  atheroma  pulp  forms  most  frequently,  hence 
aneurisms  are  most  frequent  in  them.  If  you  examine  this  atheroma- 
pulp  microscopically,  besides  the  above-mentioned  molecular  and  fat 
granules,  you  find  fat-crystals,  especially  of  cholesterine,  and  crumbs  of 
carbonate  of  lime,  also  haematoidin-crystals,  which  come  from  blood- 
clots  depositing  on  the  roughnesses  in  the  arteries, but  the  hasmatoidin 
develops  from  their  coloring  matter. 

You  have  now  a  general  \4ew  and  description  of  atheroma  in  ar- 
teries of  various  caUbre,  and  can  now  understand  how,  by  softening 
the  walls  of  the  vessels,  it  may  lead  to  partial  dilatation  of  the  artery, 
or  aneurism.  The  form  of  tliis  dilatation  may  vary  somewhat,  accord- 
ing as  the  whole  periphery  of  the  artery  is  regularly  diseased  or  not, 
and  as  softening  or  calcification  predominates. 

Tlie  dilatation  of  the  artery  may  for  some  distance  be  perfectly 
regular ;  this  is  called  aiiewysma  cylindriforme  ;  if  the  aneurism  be 
more  spindle-shaped,  it  is  teixned  aneurysma  fusiforme.  If  the  soft- 
ening be  limited  to  one  side  of  the  arterial  wall,  we  have  a  sac-like 
dilatation,  aneurysma  saccatum,  which  may  communicate  Avith  the 
cahbre  of  the  artery  by  a  larger  or  smaller  opening.  A  further  variety 
in  the  formation  of  the  aneurism  may  arise  from  aU  the  coats  regu- 
larly participating  in  the  formation  of  the  aneurism,  or  from  the 
intima  and  media  being  entirely  softened  and  destroyed,  so  that  only 
the  gradually-thickening  adventitia  and  infiltrated  surrounding  parts 
form  the  sac.  Finally,  under  the  last  conditions  the  blood  may  press 
in  between  the  media  and  adventitia,  separate  the  two  coats,  as  if  the 
layers  of  the  artery  had  been  dissected  up  anatomically ;  this  is  called 
aneurysma  dissecans.     These  divisions  may  be  carried  still  furth'^r, 


644  VARICES  AND   ANEURISMS. 

but  practically  tlicy  have  very  little  value.  I  shall  only  mention  in 
addition  that,  on  subcutaneous  bursting-  of  an  aneurism  composed  of 
all  the  arterial  coats,  it  assumes  more  the  anatomical  peculiarities  of 
an  aneurysma  traumaticum  or  spurium.  A  short  time  since  I  saw  an 
apparently  healtliy  man,  about  fifty  years  old,  who,  when  turning  in 
bed,  had  an  enormous  tumor  develop  in  the  thigh,  which  soon  proved 
to  be  a  diffuse  traumatic  aneurism  ;  I  had  no  doubt  that  the  femoral 
artery  was  diseased,  and  had  suddenly  burst  at  some  point  in  the 
middle  of  the  thigh.  After  compression  had  long  been  used  in  vain, 
the  femoral  artery  Avas  ligated ;  it  proved  to  be  covered  with  yellow 
spots ;  the  ligature  healed  well  and  became  detached  in  four  weeks, 
still  the  aneurism  became  larger  and  painful ;  tlie  sixth  week  after 
the  ligation  gangrene  of  the  foot  began ;  I  then  made  a  high  amputa- 
tion of  the  thigh  ;  the  patient  recovered.  There  Avas  an  immense  aneu- 
rysma spurium,  and  an  opening  an  inch  long  in  the  atheromatous  fem- 
oral artery,  which  Avas  not  aneurismatic. 

The  further  fate  of  the  aneurism,  and  its  ciicct  on  neighboring 
tissues  or  the  extremity  affected,  are  very  important.  As  regards  the 
anatomical  changes  in  and  about  an  aneurism,  one  is  its  increase  in 
size,  which  not  only  displaces  the  neighboring  tissues,  but,  by  its 
pressm-e  and  pulsation,  causes  them  to  atrophy  ;  this  refers  not  only 
to  the  soft  parts  but  to  the  bones,  which  are  gradually  broken  through 
by  the  aneurism ;  the  last  effect  is  especially  apt  to  be  induced  by 
aneurisms  of  the  aorta  and  anonyma,  Avhich  may  induce  atrophy  of 
tlie  vertebrae,  sternum,  or  ribs.  A  further  accompaniment  is  inflam- 
mation in  the  immediate  vicinity,  which,  however,  rarely  leads  to  sup- 
puration, often  becomes  chronic,  and  very  seldom  induces  gangrene 
of  the  anurism.  Lastly,  there  is  often  coagulation  of  blood  in  the 
aneurism  ;  hard  layers  of  fibrine  may  form  on  the  inner  surface  of  the 
sac,  and  at  last  entirely  fill  it,  and  so  cause  a  spontaneous  oblitera- 
tion, one  variety  of  cure  of  the  aneurism.  The  worst  accident  is 
when  the  aneurism  inci-eases  in  size,  and  finally  bursts;  this  may 
take  place  outwardly,  but  more  frequently,  especially  in  the  large 
arteries  of  the  trunk,  it  is  inward,  perhaps  into  the  oesophagus,  tra- 
chea, thoracic  or  abdominal  cavity ;  sudden  death  from  haemorrhage 
is  the  natural  result. 

It  is  not  our  present  object  to  shuw  wnat  may  be  the  results  of 
aneurism  of  arteries  of  internal  organs ;  I  shall  merely  mention  that 
particles  may  be  detached  from  the  clots  which  form  in  the  aneurismal 
dilatations,  or  on  the  roughnesses  of  the  atheromatous  arteries,  and 
may  pass  as  emboli  into  the  peripheral  arteries.  These  emboli  occa- 
sionally cause  gangrene ;  but  this  is  not  so  frequent  as  is  believed, 
for  usually  the  coagulje  in  aneurisms  are  firmly  attached. 


ANEURISMS   OF   THE   EXTREMITIES.  645 

We  shall  now  investigate  more  carefully  aneurisms  of  the  extrem 
ities.  At  first,  they  cause  slight  muscular  fatigue  and  weakness,  more 
rarely  pain  in  the  affected  limb;  if  there  be  inflammation  about  the 
sac,  of  course  there  are  jDuin,  redness  of  the  skin,  oedema,  and  disturl> 
ance  of  function,  which  may  go  so  far  as  to  render  the  limb  entirely 
useless  if  the  aneurism  continue  to  grow,  and  there  be  continued 
chronic  or  subacute  inflammation  around  it.  The  formation  of  exten- 
sive coagulje  in  the  aneurism  of  a  large  artery  may  be  followed  by 
gangrene  of  the  whole  limb  below  it. 

When  speaking  of  gangrene,  it  was  mentioned  that  it  might 
result  from  atheroma  of  the  artery,  as  so-called  gangrena  spon- 
tanea ;  but  there  the  case  was  somewhat  different :  the  small  arteries 
were  diseased ;  these  lose  their  power,  from  destruction  of  their  strong 
muscular  coat,  and  can  no  longer  urge  on  the  blood,  as  they  cannot 
contract.  But  here  there  is  obliteration  of  an  arterial  trunk  by  coag- 
ulte  from  an  aneurism.  I  will  relate  to  you  a  case  observed  in  the 
Zurich  surgical  clinic.  A  man  twenty-two  years  old,  emaciated  and 
miserable,  was  brought  into  the  hospital ;  his  right  leg,  nearly  as  high 
as  the  knee,  was  bluish  black,  the  epidermis  peeled  off  in  shreds ;  gan- 
grene was  unmistakable.  Examination  of  the  arteries  showed  a  spin- 
dle-shaped, pulsating  aneurism  of  the  left  [right  ?]  femoral  artery,  close 
below  Poupart's  ligament ;  there  was  a  second  one,  three  inches  below, 
on  the  same  artery ;  this  felt  hard ;  there  was  a  third  one  in  the  bend  of 
the  knee,  just  as  hard,  but,  from  the  swelling  of  the  surrounding  parts, 
the  form  could  not  be  exactly  made  out ;  between  the  second  and 
third  aneurisms  the  artery  continued  to  pulsate  the  first  day  the  pa- 
tient was  in  the  hospital ;  the  line  of  demarcation  was  not  formed,  it 
appeared  hkely  to  extend  higher ;  gradually  the  pulsation  ceased  as 
high  as  Poupart's  ligament ;  the  patient  died  about  a  fortnight  after 
his  admission  to  the  hospital.  The  autopsy  showed  the  aneurisms 
that  had  been  recognized  during  life,  and  also  extensive  atheroma  of 
almost  all  the  arteries.  Taking  this  with  what  I  told  you,  when  speak- 
ing of  the  ligation  of  large  arteries,  about  the  development  of  collateral 
circulation,  you  will  think  there  is  a  contradiction.  Why  does  not 
gangrene  occur  when  you  close  an  artery  by  a  ligature,  as  well  as 
when  it  is  blocked  by  a  clot  ?  The  answer  to  this  is,  that  a  free 
collateral  circulation  sufficient  for  the  nourishment  of  the  peripheral 
parts  onl}'  takes  place  when  the  arteries  are  healthy  and  capable  of 
distention.  But,  when  a  coagulum  passes  from  an  aneurism  into  the 
artery,  the  neighboring  arteries  are  usually  diseased  and  not  disten- 
sible, being  calcified,  or  already  partly  obstructed ;  moreover,  the 
closure  of  the  artery  is  not,  as  in  ligation,  limited  to  a  small  space,  but 
is  very  extensive,  perhaps  even,  as  in  the  case  above  mentioned,  iii' 


646  VARICES  AND  ANEURISMS. 

volvino-  the  wliole  arterj^ ;  then  there  is  no  possibility  of  a  collateral 
nirculation,  either  by  the  direct  route  or  by  neighboring  branches. 
The  arteries  must  be  very  generally  diseased,  and  the  coagulation 
very  extensive,  to  cause  gangrene,  so  that  it  is  not  very  frequent  in 
aneurism ;  that  would  also  be  very  unfortunate  for  the  treatment, 
which,  however,  as  you  will  hereafter  see,  chiefly  has  for  its  object  the 
obliteration  of  the  aneurism,  with  or  without  ligation  of  the  artery. 

"V'\^e  now  come  to  the  etiology  of  aneurism.  Although  atheroma 
is  a  very  frequent  disease  of  old  age,  and  occurs  everywhere,  aneurism 
is  bv  no  means  confined  to  old  persons.  In  Zurich,  atheroma  of  the 
arteries  in  old  persons,  and  gangrena  senilis,  are  quite  frequent,  but 
aneurism  of  the  extremities  is  rare.  The  occurrence  of  aneurism  is 
curiously  spread  over  Europe  :  in  Germany,  aneurism  of  the  extrem- 
ities is  rare  ;  it  is  somewhat  more  frequent  in  France  and  Italy,  and 
most  frequent  in  England.  It  is  difficult  to  explain  this,  only  it  is 
certain  that  diseases  of  the  arteries,  in  common  with  rheumatism  and 
gout,  are  more  frequent  in  England  than  in  any  other  country  of  Eu- 
rope. [During  the  past  five  years  (1865-1870),  of  11,344  cases  of 
disease  and  injury,  in  the  New- York  Hospital,  there  were  33  cases  of 
aneurism,  or  about  one  case  to  every  344  patients.  Of  these  there 
were :  of  the  thoracic  aorta,  6 ;  abdominal  aorta,  10 ;  innominate  artery, 
1 ;  subclavian,  2;  iliac,  1;  femoral,  4;  popliteal,  8;  not  named,  1.]  As 
regards  age  (of  course  we  are  not  speaking  of  traumatic  aneurisms), 
the  disease  is  rare  before  the  thirtieth  year,  more  frequent  between 
thirty  and  forty  years,  and  most  frequent  after  the  fortieth  year  ;  men 
are  more  disposed  to  aneurisms  than  women.  Special  causes  are  little 
known ;  popliteal  aneurism  is  most  frequent  among  those  in  the  ex- 
tremities ;  the  explanation  of  this  has  been  sought  in  the  superficial 
position  of  the  popliteal  artery,  in  the  tension  to  which  it  is  subjected 
on  sudden  movements,  contusions,  etc. ;  thus  this  form  is  said  to  occur 
especially  often  in  England  in  footmen  who  stand  behind  the  carriages ; 
but  I  must  acknowledge  that  to  me  this  seems  as  improbable  as  the 
explanation  given  for  chamber-maid's  knee.  I  am  inclined  to  believe 
that  the  tendency  to  diseases  of  the  artery,  as  to  gout,  is  due  to  heredi- 
tar}'  influence ;  hard  work  and  free  use  of  liquor  are  also  given  as  causes  ; 
in  England  especially,  the  latter  is  said  to  induce  relaxation  of  the 
walls  of  the  arter})-,  even  without  atheroma. 

The  diaff}iosis  of  an  aneurism  of  the  extremities  is  not  difficult, 
if  the  examination  be  careful  and  the  aneurism  not  too  small.  Tliere 
is  an  elastic,  more  or  less  hard,  circumscribed  (except  in  false  or  rup- 
tured aneurism,  which  are  diffuse)  tumor  connected  with  the  artery ; 
the  tumor  pulsates  perceptibly  to  the  sight  and  touch  ;  on  applying 
the  stethoscope,  you  may  hear  a  pulsating  murmur,  caused  by  the  frio- 


DIAGNOSIS   OF  ANEURISM.  647 

tion  of  the  Wood  on  tlie  coagulum,  or  in  the  opening  of  the  sac,  or  by 
the  ricochetting  of  the  blood  in  the  sac.  The  tumor  ceases  to  pulsate 
if  you  compress  the  artery  above  it.  These  symptoms  are  so  striking 
that  it  might  be  thought  the  diagnosis  could  not  be  mistaken  ;  still, 
errors  have  been  made  even  bj  experienced  surgeons,  at  times  when 
they  did  not  think  of  the  possibility  of  aneurism,  and  were  hasty. 
For,  when  the  surrounding  parts  are  much  inflamed,  the  aneurism  may 
be  greatly  masked  by  the  swelling ;  it  may  be  taken  for  a  simple  in- 
flammatory swelling  or  abscess  ;  it  may  even  have  originated  from  an 
abscess,  as  before  stated.  Tlie  latter  mistake  is  the  most  frequent ;  it 
is  punctured,  and — what  a  disagreeable  surprise — instead  of  pus,  we 
have  a  stream  of  arterial  blood.  There  is  nothing  at  hand  to  arrest 
the  haemorrhage ;  the  situation  is  shocking,  even  if  the  cool  surgeon 
have  presence  of  mind  enough  to  make  instantaneous  compression 
till  he  decides  what  next  to  do.  But  I  will  not  picture  afi'airs  too 
dismally ;  and  I  repeat  that,  on  careful  examination,  such  an  error 
would  scarcely  be  possible.  If  the  aneurism  be  distended  with  clots, 
the  pulsation  of  the  tumor  may  cease,  or  be  very  indistinct,  as  may 
also  the  murmiir ;  even  here,  however,  further  accurate  observation 
will  lead  to  a  correct  judgment.  On  the  other  hand,  a  tumor  of  a  dif- 
ferent sort  may  be  mistaken  for  an  aneurism.  In  the  bones  particu- 
larly, there  is  a  sort  of  soft  tumor  (central  osteosarcoma)  which  is 
very  rich  in  arteries,  and  consequently  pulsates  distinctly.  Numerous 
small  aneurisms  may  form  on  these  arteries,  from  the  softening  of  the 
substance  of  the  tumor  and  of  the  wails  of  the  arteries ;  the  sum  of 
the  murmurs  in  these  small  aneurisms  may  resemble  a  tj'pical  aneu- 
rismal  murmur  ;  in  these  cases  also,  only  the  most  accurate  examina- 
tion and  observation  can  show  us  the  true  state  of  the  case.  These 
pulsating  bone-tumors  are  often  regarded  as  true  aneurism  in  bone. 
I  do  not  believe  there  is  any  spontaneous  aneurism  in  bone,  but  con- 
sider all  these  so-called  bone-aneurisms  as  soft  sarcoma  in  the  bone 
very  rich  in  arteries.  Lastly,  we  may  be  tempted  to  regard  a  tumor, 
lying  very  near  an  artery  and  moved  with  the  arterial  pulse,  as  an  in- 
dependently-pulsating tumor,  or  an  aneurism  ;  the  absence  of  the 
aneurismal  murmur,  the  consistence  of  the  tumor,  the  possibility  of 
isolating  it  from  the  artery,  and  the  further  observation  of  the  course, 
will  guard  you  from  error.  The  2^^ognosis  of  aneurism  varies  greatly 
with  its  locality,  so  that  nothing  general  can  be  said  of  it. 

We  now  turn  to  the  treatment^  remarking,  first,  that  in  rare  cases 
aneurism  may  recover  spontaneously,  by  complete  closure  of  the  sac 
and  a  part  of  the  artery  by  coagula ;  the  tumor  then  ceases  growing, 
and  may  gradually  subside.  As  before  mentioned,  also,  inflammation 
aiound  the  tumor  may  lead  to  local  gangrene ;  if  the  artery  lias  pre- 


648  VARICES  AND   ANEURISMS. 

viously  been  occluded,  the  whole  aneurism  may  become  gangrenous, 
and  be  thrown  oif  without  h£emorrhage.  These  natural  cui-es  are 
very  rare,  but  indicate  the  mode  of  treatment.  I  shall  not  here  speak 
of  the  medical  treatment  of  aneurism,  except  to  mention  one  method, 
Valsalva's.  The  aim  of  this  is,  to  reduce  the  volume  of  blood  in  the 
body  to  a  minimum,  so  as  to  weaken  the  heart's  action,  and  favor  the 
formation  of  coagula.  Repeated  venesections,  purgatives,  absolute 
quiet,  low  diet,  digitalis  internally,  and  ice  locally  over  the  tumor,  are 
the  remedies  with  which  the  patient  is  treated  under  this  method;  the 
results  are  doubtful :  the  patients  are  very  much  debilitated,  and  the 
symptoms  may  then  be  less;  but,  as  the  patients  regain  their  strength, 
the  former  condition  generally  retvirns.  We  may  employ  the  above 
remedies  to  a  moderate  extent  in  alle\'iating  severe  symptoms  in  in- 
ternal aneurisms,  but  they  will  not  induce  an  actual  cure ;  unfortu- 
nately, internal  aneurisms  must  almost  always  be  regarded  as  incura- 
ble. Let  us  pass  to  the  surgical  treatment  of  external  aneurisms. 
This  may  be  conducted  in  two  waj's  ;  it  ma)'  aim  at  the  destruction  of 
the  aneurism,  or  its  complete  removal.  In  most  cases  the  destruction 
of  the  tumor  will  be  enough.     The  remedies  for  this  purpose  vary. 

1.  Compression.  This  may  be  aj)plied  in  various  wajs  :  a,  on  the 
aneurism  ;  J,  on  the  affected  artery,  above  the  tumor.  The  latter  is 
by  far  the  most  effective  method,  because  even  a  moderate  pressure 
on  the  aneurism  is  often  painful,  and  may  cause  inflammation  in  its 
vicinity.  The  mode  of  employing  compression  also  varies  ;  it  may  be 
continued,  and  complete  or  incomplete  ;  it  may  be  temporary,  but  com- 
plete, i.  e.,  such  as  to  arrest  the  pulsation.  The  methods  of  compres- 
sion are  about  as  follows  :  a,  compression  Avitli  the  fingers,  particularly 
recommended  by  Vanzetti,  and  used  by  other  surgeons  with  advantage  ; 
it  is  made  by  the  surgeon,  nurses,  or  by  the  patient  himself,  air  inter- 
vals, so  as  to  arrest  pulsation  completely  for  a  few  hours ;  if  the  patient 
can  bear  it,  this  is  continued  for  days,  weeks,  or  even  months,  till  the 
aneurism  no  longer  pulsates,  and  has  become  quite  hard  ;  J,  compres- 
sion of  the  aneurism  by  forced  flexion  of  the  extremity ;  this  procedure, 
first  used  by  Malgaigne,  is  particularly  suited  for  popliteal  aneurism ; 
the  limb  is  fastened  in  the  position  of  extreme  flexion  by  a  bandage 
and  retained  thus  till  the  pulsation  in  the  aneurism  has  ceased 
c,  compression  with  special  apparatus,  pads,  compresses,  etc.,  which 
must  be  so  made  that  the  pressure  may  be  as  much  as  possible 
on  the  artery,  and  that  oedema  may  not  be  induced  by  simultaneous 
pressure  on  the  vein  ;  the  pressure  need  not  be  hard  enough  to  arrest 
pulsation  entirely,  but  merely  to  diminish  the  supply  of  blood.  Views 
regarding  the  efficacy  of  compression  in  the  treatment  of  aneurism 
vary.     Irish  surgeons   laud  it  highly;  French   and  Italian  surgeons 


TKEATMEXT   OF  ANEURISMS.  649 

incline  to  it  more  than  formerly  ;  especially  since  the  investigations 
of  JBroca,  intermittent  digital  compression  has  shown  some  brilliant 
results.  I  think  that,  in  most  cases  of  aneurism,  compression  should 
be  first  resorted  to;  but  observation  shows  that  it  is  not  alike  suited 
for  all  cases,  and  is  not  of  radical  benefit  in  all.  [Mr.  Goote  reports  a 
case  where  aneurism  of  the  innominate  artery  was  cured  by  the  appli- 
cation of  a  bladder  of  ice.] 

2.  Ligation  of  the  artery.  This  may  be  done  in  various  ways : 
a,  close  above  the  aneurism  (after  Anel)  ;  h,  far  above  the  aneurism, 
at  a  point  of  election  {J.  Hunter) ;  c,  close  below  the  aneujism,  i.  e., 
at  its  peripheral  end  (after  Warclrojy  and  Brasdor).  Of  all  these 
methods,  ligation  close  above  the  aneurism  is  proportionately  the 
most  certain ;  ligation  close  below  it  the  least  certain.  Ligation  at 
a  distance  from  the  aneurism  will  cure  the  disease  for  a  short  time, 
occasionally  even  permanentl}^,  i.  e.,  the  pulsation  in  the  aneurism 
will  cease,  but,  when  the  collateral  circulation  develops  fully,  the 
pulsation  may  begin  again.  I  have  myself  seen  such  a  case ;  from  a 
puncture  with  a  penknife,  a  boy  twelve  years  old  had  an  aneuristn 
the  size  of  a  large  Avalnut  in  the  femoral  artery,  about  the  middle  of 
the  thigh  ;  the  femoral  was  ligated  close  below  Poupart's  ligament ; 
in  ten  days  the  ligature  cut  through,  and  there  was  great  liEemor- 
rhage,  which,  however,  was  instantly  checked ;  then,  after  di\dding 
Poupart's  ligament,  a  second  ligature  was  applied  half  an  inch  higher ; 
this  ligature  held  well ;  the  wound  healed  ;  when  the  patient  left  the 
hospital  there  was  again  pulsation  in  the  anem'ism,  which  had  previously 
become  perfectly  hard,  and  had  ceased  pulsating.  But,  in  spite  of  such 
relapses,  ligation  remote  from  the  aneurism  will  retain  its  importance, 
and  continue  the  chief  method,  for,  in  the  vicinity  of  the  aneurism, 
the  artery  is  occasionally  so  diseased  that  it  is  not  advisable  to  ligate 
there ;  for  the  rigid  and  ossified  artery  might  be  so  quicldy  cut 
through  by  the  ligature  that  the  thrombus  would  not  be  firm  enough 
when  the  ligature  falls. 

3.  Remedies  which  are  supposed  to  directly  induce  coagulation  ot 
the  blood  in  aneurisms.  Of  these,  injection  of  liquor  feri'i  sesqui- 
chlorati,  after  Pravaz  and  Petrequin,  is  relatively  most  frequently 
used ;  it  must  be  done  very  carefully :  it  should  be  made  with  a  small 
syringe,  whose  piston  is  moved  by  a  screw,  with  every  turn  of  which 
a  drop  escapes ;  a  few  drops  of  the  liquor  ferri  should  thus  be  very 
carefully  forced  into  the  tumor.  Simple  coagulation  and  shrinking 
of  the  aneurism  may,  and  it  is  said  do,  follow  this ;  but  experience 
has  shown  that  it  is  more  frequently  followed  by  inflammation,  sup- 
puration, and  gangrene.     I  think  that  the  action  of  the  injected  liquoi 


650  VARICES  AND   ANEURISMS. 

ferri  is  misunderstood ;  for  it  is  not  probable  tliat  a  clot  made  by  this 
substance  becomes  organized ;  it  most  likely  merely  irritates  the  wall 
of  the  vessel,  causing  it  to  inflame,  and  thereby  lose  the  power  of 
keeping  the  blood  fluid  {JBrUc/ce),  thus  secondarily  inducing  coagula- 
tion of  that  fluid  and  atrophy  of  the  walls  of  the  artery.  Vbu  Lan- 
genheck  injected  a  solution  of  ergotin  into  the  immediate  vicinity  of 
an  aneurism  and  cured  it.  I  exjDlain  the  action  here  also  as  being  an 
inflammation  of  the  wall  of  the  vessel,  with  the  results  above  men- 
tioned. Electropuncture,  nearly  abandoned  for  a  time,  has  been  again 
resorted  to  by  Glniselli,  and  with  very  good  results,  even  in  aortic 
aneurism ;  a  needle  is  to  be  passed  into  the  aneurism  and  connected 
to  the  negative  pole  of  a  galvanic  battery,  while  the  positive  pole  is 
to  be  applied  to  any  part  of  the  body.  [In  an  interesting  case  re- 
ported by  Dr.  M.  JP.  Lincoln,  in  the  Medical  Record,  the  current 
was  passed  directly  through  needles  introduced  into  the  tumor.] 
Formerly  it  was  thought  that  the  galvanic  current  had  the  power  ol 
coao-ulating  the  blood  directly.  [This  Avould  seem  to  have  occurred  in 
Lincohi's  case,  as  clotted  blood  escaped  from  the  needle-punctures.] 
Physiologists  do  not  consider  this  the  mode  of  action,  but  think  that 
the  thermic  efi'ect  of  the  current  causes  a  small  eschar  around  the 
needle  in  the  aneurism,  and  that  the  clot  forms  around  this.  If  we 
pass  several  fine  needles  into  an  aneurism  and  leave  them  twenty-four 
to  forty  eight  hours,  they  also  will  cause  inflammation  and  formation 
of  a  clot.  [At  a  meeting  of  the  New  York  Pathological  Society,  Dr. 
Gurdon  Buck  presented  a  specimen  where  needles  had  been  used, 
and  spoke  of  one  where  silk  sutures  had  been  employed  ;  he  gave  it  as 
his  opinion  that,  in  view  of  the  liability  to  inflammation,  such  proced- 
ures were  inadmissible  in  arteries  near  the  heart.] 

4.  We  now  come  to  the  mode  of  operative  treatment  of  an  aneu- 
rism which  aims  at  its  complete  destruction;  if  this  succeed,  it  is 
of  course,  more  certainly  a  radical  cure  than  the  modes  above  de- 
scribed, but  it  is  a  much  more  serious  operation.  It  may  be  done, 
according  to  Antyllus,  as  follows :  The  artery  is  to  be  compressed 
above  the  aneurism,  then  the  whole  sac  is  slit  up  and  the  coagulum 
turned  out ;  through  the  sac  probes  are  passed  into  the  upper  and 
lower  ends  of  the  artery,  which  is  then  ligated,  the  probes  of  course 
being  removed — they  are  only  intended  to  facilitate  finding  the  artery ; 
this  operation,  which  I  have  seen  performed  several  times  for  aneu- 
risms resulting  from  venesection,  is  not  always  as  simple  as  it  appears, 
for  it  is  not  at  all  times  easy  to  find  the  openings  of  the  artery  in  the 
sac  filled  with  coagulum,  and  often  other  arteries  besides  the  main  one 
bleed,  as  a  collateral  circulation  occasionally  opens  into  the  aneurism. 


TREATMENT   OF   CIRSOID   ANEURISM.  651 

After  the  oi")eralion  there  is  suppuration  of  the  whole  aneurismal 
sac ;  in  three  cases  of  traumatic  anevirism  of  the  brachial,  and  one  of  the 
radial  arter}^,  I  saw  healing  occur  without  any  accident.  If  the  aneu- 
rism be  small  and  distinctly  bounded,  we  might  first  ligate  above  and 
below,  then  extirpate  the  aneurism  as  we  would  a  tumor.  Of  late, 
Syme  has  employed  the  method  of  Antyllus  successfully  in  large 
arteries  also. 

I  should  like  to  give  you  some  definite  advice  about  the  choice  of 
method  among  these  different  plans  of  operating,  but  this  is  scarcely 
possible,  as  one  plan  or  another  will  best  suit  difTerent  cases.  In  gen- 
eral terms,  I  can  merely  repeat  that  of  late  so  many  favorable  results 
from  compression  have  again  been  published  from  different  sources, 
that  it  should  not  be  too  quickly  abandoned.  If,  however,  as  usually 
happens  in  aneurisms  from  venesection,  there  be  great  diffuse  swell- 
ing of  the  entire  arm,  the  method  of  Antyllus  appears  to  me  prefer- 
able to  all  others ;  Avith  good  assistants  it  is  very  practicable,  and  is 
not  so  dangerous  as  is  claimed  by  many  persons.  When  we  do  not 
wish  to  make  Antyllus' s  operation,  we  may  try  AnePs  or  Hunter^s.  I 
have  least  to  say  for  the  injection  of  liquor  ferri  in  ordinary  cases  of 
spontaneous  and  traumatic  aneurism.  In  varicose  aneurism  and 
aneurismal  varix,  ligating  the  artery  above  and  below  the  opening 
will  be  the  most  certain  method. 

[In  the  diagnosis  of  external  aneurisms  we  may  place  the  hand, 
with  the  fingers  slightly  spread,  over  the  tumor  ;  if  the  pulsation 
is  not  aneurismal  the  hand  is  simply  moved,  but  if  it  be  so  the  fin- 
gers are  separated  still  more.  In  the  former  case  the  pulsation  is 
due  to  a  cavity  filled  with  fluid,  or  some  other  tumor  pressing  on 
an  artery. 

For  treating  aneurisms  by  compression  one  of  the  simplest  plans 
is  by  means  of  a  rod  with  its  upper  end  against  the  ceiling  or  a 
framework  over  the  bed,  and  the  lower  end  on  a  cushion  lying  on 
the  artery  ;  the  vessel  is  thus  compressed  by  the  rod  till  the  pulsation 
ceases. 

Another  method  is  compression  of  the  limb  till  it  is  bloodless, 
by  EsmarcKs  elastic  bandage.  This  may  be  applied  daily  with 
moderate  pressure  from  the  periphery  to  a  point  above  the  aneu- 
rism ;  then  apply  an  elastic  tube  and  remove  the  bandage  ;  thus  the 
part  supplied  by  the  diseased  artery  is  cut  off  from  the  circulation. 
Complete  compression  is  maintained  from  three  to  five  minutes  at 
first,  and  later  for  a  longer  time.  Before  removing  the  tube  the 
elastic  bandage  should  again  be  applied  so  as  to  make  slight  press- 
ure, and  then  the  blood  be  allowed  to  enter  the  artery.  Thus  com- 
plete compression  is  aided  by  moderate  pressure  in  the  intervals. 


652  VARICES   AND   ANEURISMS. 

When  an  operation  has  been  performed  under  EsmarcKs  band- 
age, after  ligating  all  the  vessels  we  can  find,  we  may  tampon  the 
sac  with  carbolized  gauze,  apply  an  exact  comjiressive  bandage 
from  the  periphery  ujDward,  and  then  remove  the  tube.  Then  ele- 
vate the  limb  to  facilitate  venous  circulation.  Sometimes  there  is 
suppuration  from  the  sac,  particularly  if  all  clots  have  not  been  re- 
moved ;  but  this  does  not  hinder  cicatrization. 

In  ligating  atheromatous  arteries  it  is  advantageous  to  u?e  liga- 
tures of  material  which  may  heal  in  the  tissue,  because  this  enables 
us  to  unite  the  incision  by  first  intention.  Instead  of  catgut  liga- 
tures, which  are  uncertain,  as  they  sometimes  absorb  quickly,  I  use 
fine  silk  ligatures  that  have  been  soaked  an  hour  in  a  four-per-cent. 
solution  of  carbolic  acid  and  then  kept  in  antiseptic  fluid  in  a  well- 
covered  vessel.  This  silk  causes  as  little  reaction  as  catgut,  and 
gives  all  possible  security  against  rapid  solution  of  the  ligature  be- 
fore the  thrombus  is  organized.] 

We  must  still  add  a  few  remarks  about  the  treatment  of  cirsoid 
aneurism.  The  above  methods  of  operation  are  only  partially  appli- 
cable to  it.  Direct  compression  of  the  entire  tumor  may  be  made 
by  means  of  bandages  and  compresses  prepared  for  the  special  cases  ; 
we  mean  particularly  the  aneurisms  of  this  variety  coming  on  the 
head  which  are  the  most  frequent,  but  compression  has  rarely  proved 
successful.  The  injection  of  liquor  ferri  may  here  prove  useful,  for 
suppuration  or  gangrene  of  the  entire  convolution  of  arteries  is 
not  so  much  to  be  feared  as  in  aneurisms  of  the  large  arteries  of  the 
extremities.  The  destruction  might  be  accomplished  by  ligating  all 
the  afferent  arteries,  but  this  is  very  tedious  and  uncertain  ;  the  re- 
sult would  be  just  as  doubtful,  and  it  might  be  dangerous  to  ligate 
one  or  both  external  carotids  in  a  cirsoid  aneurism  of  the  scalp. 
Another  method,  having  the  same  object,  is  to  insert  insect-needles 
through  the  skin  at  different  points  around  the  tumor,  and  apply  a 
thread,  as  in  the  twisted  suture  ;  the  result  will  be  suppuration  and 
obliteration,  perhaps  partial  gangrene  of  the  skin.  Total  extirpation 
may  occasionally  be  resorted  to  ;  it  is  done  as  follows  :  Around  the 
tumor  we  make  numerous  percutaneous  mediate  ligations  close  to- 
gether ;  then  we  may  cut  out  the  main  body  of  the  tumor,  with  the 
dilated  arteries,  without  hemorrhage  ;  this  is  the  most  certain  and 
radical  operation,  but  cannot  well  be  resorted  to  when  the  tumors 
are  very  extensive  ;  then  we  might  try  mediate  ligation  for  different 
parts,  and  attain  our  end  by  partial  extirpations.  After  his  very 
thorough  investigations  about  the  treatment  of  these  aneurisms, 
Heine  also  speaks  very  decidedly  in  favor  of  their  extirpation. 


I 


TREATMEXT   OF   CIRSOID   ANEURISM.  653 

Careful  examinations  of  veins  by  Sohoroffh^^Q  shown  thaf  their 
walls  are  in  very  different  conditions  ;  he  examined  especially  the 
saphenous  vein  and  its  branches  (Fig.  113)  ;  he  found  that  normally 
in  different  persons  its  layers  varied  essentially,  and  that  even  ad- 
jacent parts  of  the  same  vein  were  not  exactly  alike.  This  is  very 
interesting,  for  it  explains  why  the  occurrence  of  varices  is  so  un- 
equally induced  by  the  same  cause,  and  is  due  to  purely  individual 
cu'cumstances.  Among  varicose  veins  we  may  distinguish  those 
with  thin  and  those  with  thick  walls.  The  enlargement  of  the  mus- 
cular filaments  and  the  lack  of  change  in  the  endothelium  are  com- 
mon to  all.  The  variation  in  the  diameter  of  the  walls  of  the  veins 
is  chiefly  due  to  thickening  of  the  adventitia,  whose  vessels  also  in- 
crease, and  of  the  cement  which  unites  the  muscular  filaments  ; 
slightly  also  to  thickening  of  the  intima  ;  but  sclerosis  of  the  latter, 
as  in  arterial  sclerosis,  is  very  rare.  Hence,  under  increased  press- 
ure the  anatomical  conditions  in  the  walls  of  veins  are  the  same  as 
in  the  urinary  bladder  and  heart  under  similar  circumstances.  At 
first,  in  consequence  of  increased  functional  demands,  the  muscular 
filaments  seem  to  grow  ;  if  then  nutrition  is  increased  by  increase 
of  the  vasa  vasorum,  the  connective  tissue,  especially  the  adventitia, 
is  decidedly  increased  ;  if  the  nutrition  be  not  increased,  there  is 
atrophy  and  total  relaxation. 

[At  present,  with  the  aid  of  antiseptic  treatment,  operations  for 
varicose  veins,  after  being  for  a  time  partly  abandoned,  have  again 
been  resumed.  After  applying  EsmarclCs  bandage  we  may  apply 
double  ligatures  to  some  of  the  varices  of  the  leg  and  then  remove 
them.  Catgut  ligatures  have  been  passed  through  the  skin  and  be- 
hind the  varicose  vein  at  the  central  and  peripheral  end  of  the 
varicosity,  and  then  tied  over  a  bit  of  rubber  tubing.  None  of 
these  operations  are  entirely  free  from  danger  from  the  thrombosis 
which  must  occur  and  may  cause  death,  nor  do  they  radically  cure 
the  disease.  Of  what  use  is  it  to  cut  off  a  few  bi-anches  of  the 
dilated  venous  system  of  the  leg,  for  instance  ?  In  a  short  time 
other  branches  will  become  varicose.  Experience  accords  with  this 
theoretical  reasoning  ;  so  do  not  operate  for  varices  without  some 
urgent  reason. 

Patients  who  can  afford  it  may  wear  thin  rubber  bandages  {JSLir- 
tin's);  they  are  cheaper  and  moi-e  durable  than  elastic  stockings,  and 
may  be  worn  even  when  there  are  varicose  ulcers  ;  these  may  be 
coated  with  a  mixture  of  iodoform  and  mucilage,  and  the  elastic 
bandage  be  applied  not  very  tightly  every  morning  and  removed  at 
night. 

To  diminish  very  extensive  varicosities  we  may  resort  to  a  pro- 


g54  VARICES   AND   ANEUEISMS. 

ceclure  recently  employed,  aiming  at  shrinkage  of  the  tissue  around 
the  veins  and  consequently  of  the  dilatations,  which  is  far  less  dan- 
gerous than  other  operations.  This  is  the  subcutaneous  injection 
of  certain  fluids  (dilute  alcohol,  ergotine,  etc.),  not  into  the  veins, 
but  into  the  tissue  around  them  ;  this  induces  local,  sometimes  se- 
vere inflammation,  which,  however,  does  not  usually  advance  to 
formation  of  abscess,  but  only  to  cicatrization  and  shrinkage  of 
the  perivenous  tissue  ;  if  these  injections  be  repeated  at  various 
points  for  a  long  time,  they  may  cause  obliteration  of  the  veins. 
This  method  is  greatly  praised  by  Schioalhe  and  EiKjUsch.^ 


CHAPTER  XX. 
TUIIOHS. 


l.ECTURE   XLIV. 

Definition  of  the  Terro  Tumor. — General  Anatomical  Eemarks;  Polymorphism  of 
Tissues. — Points  of  Origin  of  Tumors. — Limitation  of  the  Development  of  Cells  to 
Certain  Types  of  Tissue. — Eelation  to  the  Generative  Layers. — Mode  of  Growth. — 
Anatomical  Metamorphosis  of  Tumors  ;  their  External  Appearances. 

Gentlemen  :  To-day  we  enter  on  the  difficult  chapter  that  treats 
of  tumors.  The  swellings  of  which  we  have  hitherto  spoken  depended 
only  on  a  few  causes ;  they  were  due  to  abnormal  collections  of  blood 
in  and  outside  of  the  vessels,  to  infiltration  of  the  tissue  with  serum, 
to  its  permeation  with  young-  cells  (plastic  infiltration),  either  sepa- 
rately or  in  combination.  In  contradistinction  to  these  swellings,  we 
now  in  the  clinical  sense  of  the  term  call  new  formations  sioellings 
or  tumors  when  we  suppose  they  are  due  to  other  causes  than  those 
of  the  inflammatory  new  formations,  and  have  a  growth  which  as  a 
rule  has  no  typical  termination,  but,  as  it  were,  goes  on  ad  infinitum  / 
besides,  most  of  these  growths  are  composed  of  tissue  which  is  more 
highly  organized  than  inflammatory  neoplasia.  Let  us  investigate 
this  more  accurately.  At  present  you  are  only  acquainted  with  that 
variety  of  new  formation  caused  by  inflammation ;  this  is  very  uni- 
form, not  onl}^  in  its  mode  of  origin,  but  in  its  further  development ; 
its  development  might  be  interfered  with  by  disintegration,  drjdng  up, 
breaking  down  into  pus,  etc. ;  it  might  proliferate  excessively,  but  it 
was  always  in  such  a  way  as  not  to  change  its  character;  but,  finally, 
if  there  existed  no  specially  unfavorable  local  or  general  cause,  and 
no  vital  organ  was  disturbed  by  the  new  formation,  it  subsided — it 
again  became  connective  tissue;  the  inflammation  terminated  in  cica- 
trization. Then,  if  the  inflammation  was  superficial,  there  was  de- 
velopment of  epithelial  or  epidermis  cells,  the  bon}-  cicatrix  ossified, 


656 


TUMORS. 


new  nerve-filaments  formed  in  the  nerve-cicatrix  ;  in  all  these  changes 
the  development  of  new  blood-vessels  played  an  important  part ;  still, 
as  above  said,  the  typical  termination  of  the  inflammation,  whether  it 
was  acvite  or  chronic,  superficial  or  deep,  was  in  the  cicatrix. 

Although  connective  tissue,  nerve,  and  bone  tumors,  may  ex- 
ceptionally form  from  connective  tissue,  nerve,  and  bone  cicatrices, 
still  these  constitute  a  very  small  part  of  the  various  tissue-formations 
found  in  tumors;  forms  the  most  varied  and  complicated,  such  as 
newly -formed  glands,  teeth,  hair,  etc.,  are  occasionally  to  be  found  in 
the  tumors ;  indeed,  tissues  are  there  seen  which,  as  then  arranged, 
never  imder  other  circumstances  occur  in  the  body  or  even  during 
foetal  life.  To  enable  you  to  form  a  correct  idea  of  the  anatomical 
characteristics  of  tumors,  I  will  recall  to  your  memory  a  few  general 
laws  from  general  pathology  about  the  formation  of  new  growths ;  in 
the  large  works  on  this  subject  by  VircJiow  and  0.  Weber  you  may 
find  very  excellent  and  exhaustive  representations  of  these  conditions. 

When  a  part  of  the  body  is  abnormally  enlarged,  we  make  a  dis- 
tinction as  to  whether  the  enlargement  is  caused  by  an  abnormal  in- 
crease of  volume  of  the  different  elements  {sim2)le  hypertrophy)  or  by 
a  formation  of  new  elements,  which  are  deposited  between  the  old 
ones.  This  new  formation  may  be  analogous  to  the  matrix,  or  mother- 
tissue  {homoeoplastic)^  or  not  [heteroplastic).  The  homoeoplastic  new 
formation  proceeds  either  from  simple  division  of  the  existing  ele- 
ments (thus  a  cartilage-cell  by  segmentation  forms  two,  then  four 
cartilage-cells)  ;  then  it  is  called  hyperplastic  (numerical  hypertrophy) ; 
or  at  first  apparently  indiff'erent,  small,  round  cells  form  from  the  ex- 
isting cellular  elements,  and  from  these  a  tissue  analogous  to  the  mat- 
rix is  developed — homoeoplastic  new  formation  in  the  strict  sense. 
Heteroplastic  new  formations  always  begin  with  the  development  of 
primary  cell-tissue,  so-called  indiff'erent  formative  cells  (gi-anulation 
stage  of  tumors,  Yi7'choio),  and  from  these  develops  the  tissue  heterolo- 
gous to  the  matrix  (as  cartilage  in  the  testicle,  eiDidermis  in  the 
brain,  etc.). 

This  nomenclature,  proposed  by  Virchow,  seemed  perfectly  suit- 
able and  natural  in  a  purely  anatomical  point  of  view  ;  and  I  can  still 
accept  it  if  the  term  of  heteroplasia  be  limited,  as  will  be  hereafter 
stated,  and  if  Ave  dismiss  the  idea  that  homoeoplastic  is  synonymous 
with  benignant  and  heteroplastic  with  malignant.  We  must  here  add 
that  there  is  every  probability  that  wanclerh^g  cells  escaping  from  the 
vessels  very  materially  aid  in  the  formation  of  tumors,  at  least  to  the 
formation  of  tumors  of  the  connective-tissue  series.  But,  apart  from 
this,  we  should  err  if  we  supposed  that  in  the  above  nomenclature  all 
cases  of  new  formation,  even  considered  in  a  purely  anatomical  point 


GENERAL  REMARKS  ABOUT  TUMORS.  657 

of  view,  could  be  easily  labelled,  ready  to  be  placed  away  in  a 
museum.  The  simple  nuraeiieal  hypertrophies  and  hypeqDlasioe,  al- 
though in  some  cases  difficult  to  distinguish,  are  at  least  theoretically 
separable ;  the  same  way  with  those  new  formations  which  do  not 
consist  of  similar,  well-formed  tissue-elements ;  a  connective-tissue 
tumor  occurring  in  connective  tissue  would  always  be  termed  homoso- 
plastic ;  found  in  bone,  brain,  or  the  liver,  it  would  be  termed  hetero- 
plastic, etc.  Well-developed  alveolar  cancerous  tissue  also  usually 
presents  no  difficulty  of  classification,  for  it  does  not  normally  occur 
in  any  part  of  the  body,  it  is  everjrwhere  heterologous.  But  what 
shall  we  say  of  the  neoplasia  which  have  no  fully-developed  normal 
or  entirely  abnormal  form  of  tissue,  but  consist  of  elements  that  can- 
not be  found  elsewhere ;  what  becomes  of  them  ?  or,  can  any  thing 
develop  from  them  (indilFerent  formative  cells,  primarj'-cell  tissue, 
granulation-tumors)  ?  and  where  shall  we  place  those  neoplasite  which 
are  not  completed  tissue,  but  are  evidently  normal  tissue  in  the  stage 
of  development  ?  According  to  the  above  definition  of  heterology  and 
homology,  inflammatory  new  formation  is  at  first  heterologous  every- 
where; but  the  ■  connective-tissue  cicatrix  developing  from  it  subse- 
quently becomes  a  homologous  neoplasia  in  connective  tissue ;  in  mus- 
cle it  almost  always  remains  heterologous,  the  same  way  in  the  brain 
and  in  the  bones,  if  it  does  not  ossify.  You  see  that  here  parts, 
which  from  their  nature  and  mode  of  origin  naturally  belong  together, 
are  sundered  by  the  anatomical  nomenclature.  But  let  us  leave  in- 
flammatory neoplasiiB  out  of  the  question.  Every  tumor  resulting 
from  indifferent  formative  cells  must  exhibit  a  series  of  stages  of  de- 
velopment, if  the  cells  are  transformed  to  one  or  several  sorts  of  tis- 
sue. Wherever  they  are  grouped  together,  indifferent  formative  cells 
are  heterologous ;  if  a  neoplasia  show  only  such  elements,  we  will  let 
it  pass  for  heterologous ;  but  if  it  appear  that  a  number  of  these  cells 
have  been  transformed  into  spindle-cells,  the  question  arises,  Where 
does  this  neoplasia  belong  ?  Spindle-cells  collected  in  groups  are 
heteroplastic  in  all  parts  of  the  body ;  but  these  cells  occur  in  foetal 
connective  tissue,  foetal  muscles,  and  foetal  nerves  ;  what  would  finally 
become  of  the  spindle-cells  of  this  tumor?  if  found  in  muscles,  should 
not  this  tumor  still  be  called  homologous  ?  On  this  point  we  can  only 
decide  arbitrarily ;  you  may  look  at  it  from  different  points  of  view. 
Now,  what  shall  we  do  with  tumors  that  contain  the  most  different 
complete  and  incomplete  tissues  ?  I  will  stop  here,  to  avoid  making 
you  skeptical ;  it  is  m}-  duty  to  help  you  learn,  not  to  throw  obstacles 
in  your  way. 

As    the  enlargement   of  the   individual  elements  (simple    hyper- 
trophy) cannot  be  observed,  and  the  increase  of  the  elements  from 
43 


658  TUMORS. 

tlieinselves  (hyperplasia)  is  ac  act  often  observed  and  constantly  go- 
ing on  in  physiological  growth,  it  only  remains  to  treat  of  the  point 
of  origin  of  the  indifferent  formative  cells,  and  their  further  course. 
Here  we  find  ourselves  in  the  same  position  as  in  inflammation,  onlj 
in  regard  to  the  development  of  tumors  we  unfortunately  cannot  make 
any  experimental  investigations.  Formerly  the  proliferation  of  con- 
nective-tissue cells  was  not  doubted,  and  these  were  assumed  as  the 
source  for  the  development  of  most  tumors.  But  most,  possibly  all, 
of  these  indifferent  cells  are  wandering  white  blood-cells.  There  is 
little  doubt  that  on  this  point  there  was  formerly  much  error,  conclu- 
sions having  been  too  quickly  drawn  from  the  arrangement  in  groups, 
and  the  metamorphoses  of  the  formative  cells  ;  nor  can  I  claim  to  have 
escaped  these  errors.  For  instance,  when  in  sarcoma  we  found  small 
indifferent  cells,  with  one,  two,  and  then  more  nuclei  near  together 
(when  between  the  filaments  of  the  connective  tissue,  where  the  con- 
nective-tissue cells  lie,  we  saw  a  small,  then,  near  by,  a  large  group  of 
indifferent  cells),  the  conclusion  tliat  the  new  groups  of  cells  were  deriv- 
atives from  the  connective-tissue  cells  seemed  quite  unpiejudiced  ;  also, 
that  from  these  indifferent  cells,  larger  multinucleated  ones  were  con- 
stantly developed  till  the  so-called  giant-cells  were  arrived  at.  Know- 
ing now  that  an  infiltration  of  the  tissue  with  small  cells  may  depend 
on  escape  of  white  blood-cells  from  the  vessels  into  the  tissue ;  as  be- 
fore remarked,  we  also  become  doubtful  about  the  origin  of  the  indif- 
ferent formative  cells  in  the  tumors.  Of  late,  especiall}'^  in  glandular 
and  epithelial  cancer,  I  usually  seek  in  vain  for  proliferating  connec- 
tive-tissue cells,  although  the  whole  connective-tissue  layer  of  these 
tumors  is  generally  infiltrated  with  young  cells.  The  deep  ob- 
scurity which  had  surrounded  the  origin  of  young  epithelial  cells 
has  only  lately  been  cleared  awa}^  From  the  latest  investiga- 
tions we  know  that  these  cells  increase  by  a  sort  of  segmenta- 
tion. I  must  here  remind  you  of  what  was  said  about  the  regen- 
eration of  tissue  in  inflammation  (Lecture  XXII.).  From  ArnohPs 
observations  we  may  suppose  that,  in  the  development  of  tumors, 
protoplasm  which  has  been  fully  changed. to  tissue  may  possibly  pass 
into  a  granular  condition,  a  nucleus  may  form  in  it,  and  it  may  then 
proliferate,  and  segmentation  occur  as  it  does  in  cells ;  in  which 
case  new  tissue  is  first  formed  when  the  granular  protoplasm  lias 
changed  into  cells ;  so  that  Schwanii's  law  that  "  all  tissues  are 
formed  from  cells"  is  not  broken,  although  there  is  a  modification  of 
the  law  that  "  every  cell  comes  from  a  cell." 

We  have  frequently  spoken  of  indifferent  formative  cells,  without 
having  sufficiently  defined  this  term.  By  these  we  mean  the  small, 
round  cells  which  everywhere  first  appear  after  irritating  the  tissue. 


GENERAL  REMARKS  ABOUT  TUMORS.  659 

and  with  which  we  became  accjuainted  in  inflammatory  new  forma- 
tions. Until  within  a  few  years  I  believed  that  these  young  cells 
were  actually  as  indifferent  as  the  primary  segmentation-globules  of 
the  egg  [vitelline  spheres  of  Dalton],  i.  e.,  that  any  tissue  might 
finally  develop  from  them  ;  and  more  especially  I  thought  that  not 
only  all  forms  of  connective-tissue  substances  (connective  tissue, 
cartilage,  bone),  vessels,  and  nerves,  but  also  epithelial  tissues, 
glands,  etc.,  could  proceed  from  the  derivatives  of  the  connective- 
tissue  cells.  Against  this  still  prevalent  view  Thiersch,  in  an  excel- 
lent work  on  "  epithelial  cancer,"  has  produced  such  proofs  that  I 
must  entirely  agree  with  him.  As  I  propose  returning  to  this  point 
hereafter,  when  treating  of  cysts,  glandular  tumors,  and  epithelial 
cancers,  I  shall  here  merely  point  out  the  general  outlines  of  my 
views.  From  the  account  of  development  you  know  that  the  body 
of  the  young  embryo  very  early  shows  three  different  layers,  so- 
called  germ-layers.  As  soon  as  the  division  of  the  cellular  embryo- 
nal elements  into  the  three  germ-layers  is  accomplished,  all  observers 
agree  that  each  of  these  three  germ-layers  produces  only  a  certain 
series  of  tissues.  From  the  horny  layer  are  formed  the  nerve-sys- 
tem, the  epidermis,  and  their  derivatives,  the  cutaneous  glands,  the 
sexual  glands,  the  labyrinth  of  the  ear,  the  lens ;  from  the  middle 
germ-layer  are  formed  the  connective  substance,  the  muscles  (?),  the 
vascular  system,  the  lymphatic  glands,  the  spleen,  the  peripheral 
nerves  (?) ;  from  the  inferior  or  glandular  layer  are  formed  the  epi- 
thelium of  the  intestinal  canal,  that  of  the  lungs  (?),  all  the  secret- 
ing elements  of  the  liver,  pancreas,  kidneys,  etc.  Tliis  is  one  of 
nature's  laws,  for  whose  discovery  we  are  greatly  indebted  to  Me- 
mak,  Meichert,  Kolliher,  Hels,  Waldeyer,  and  others,  and  which 
may  probably  be  carried  back  into  the  composition  of  the  ovum. 
In  the  whole  subsequent  course  of  development  a  derivative  of  one 
germ-layer  never  develops  a  tissue  which  was  originally  formed 
from  another  ;  in  other  words,  if  the  division  of  the  cellular  embryo- 
nal plan  has  advanced  to  the  three  germ-layers,  there  are  no  more 
wholly  indifferent  cells,  but  all  newly-formed  cells  developed  from 
previous  ones  can  only  develop  to  tissues  lying  within  the  territory 
of  the  germ-layer  whence  they  originate  ;  cells  originating  from 
true  genuine  epithelium  can  never  produce  connective  tissue,  and 
true  epithelium  or  glands  can  never  come  from  the  derivatives  of 
connective-tissue  cells.  There  is  no  reason  for  supposing  that  the 
natural  law  would  be  annulled  if  the  cellular  elements  of  the  com- 
plete organism  were  excited  to  production  by  any  irritation  ;  the 
young  brood  can  only  develop  to  certain  prescribed  types  of  tissue, 
which  depend  on  the  embryonal  origin  of  the  mother-cells.     When 


660 


TUMORS. 


we  have  spoken,  or  in  future  speak,  of  indiiferent  cells,  you  must  al- 
ways limit  the  expression  by  the  principles  above  developed.  If  we 
now  return  to  the  system  of  new  formation  developed  by  Virchoio, 
accordino-  to  our  view  there  is  no  such  thing  as  a  true  heteroplasia, 
for  the  germ-cells  formed  from  the  derivatives  of  one  germ-layer  can 
only  develop  differently  within  certain  bounds  ;  they  can  never  be- 
come one  of  the  types  of  tissue  belonging  to  another  germ-layer. 
From  the  great  movements  constantly  being  made  in  histogeny, 
any  very  absolute  assertion  is  in  danger  of  being  obliged  soon  to 
submit  to  some  modification  ;  still  I  must  repeat  that  it  seems  to 
me  in  the  highest  degree  probable  that  a  large  part  of  the  young 
cells  escaping  so  extensively  into  the  tissues  during  the  develop- 
ment of  tumors  are  movable,  wandering,  connective-tissue  cells,  that 
is,  escaped  white  blood-cells.  Nevertheless,  I  would  not  deny  to 
the  stable  elements  all  participation  in  the  new  tissue  formation. 
For  instance,  it  has  been  proved  of  muscular  filaments  that  their 
cells  proliferate  after  irritation,  by  division  of  the  nuclei,  although 
this  may  not  occur  for  some  time  (in  rabbits  about  the  end  of  the 
first  week)  ;  the  same  is  true  of  the  nerves;  the  cartilage-cells  also 
react  on  irritation,  although  not  for  some  time.  It  is  uncertain 
whence  the  wandering  cells  come  (they  are  identical  with  white 
blood-cells  ancl  lymph-cells) ;  probably  their  original  source  is  from 
stable  elements  of  the  lymphatic  glands  and  spleen ;  at  all  events, 
they  must  be  regarded  as  elements  of  the  middle  germ-layer,  and 
hence  their  powers  of  development  must  be  regarded  as  limited  to 
the  tissues  of  this  layer.  Our  times  may  look  with  pride  at  the  pro- 
gress of  modern  morphology,  whose  importance  is  proved  by  the 
verv  fact  that  it  is  so  destructive  to  previous  views  and  so  fruitful 
in  the  most  diverse  directions. 

When  some  investigators  on  this  point  assert  that  the  conditions 
of  embryonal  development  just  given  have  no  claim  to  pass  as  im- 
mutable laws  of  nature,  but  only  serve  as  rules  for  the  development 
of  the  more  highly-organized  animals,  I  must  leave  the  embi-yologists 
to  maintain  the  argument.  But  I  would  entirely  deny  the  assertion 
that  types  of  development  which  are  recognized  in  embryology  have 
no  analogy  in  neoplasms  which  result  from  various  irritations  of  de- 
veloped tissue  ;  for  all  modern  histogeny  is  based  on  the  principle 
that  development  of  pathological  neoplasia  is  only  a  repetition  of 
typical  development  of  normal  tissice^  vf\\ic\\  has  been  generally  ac- 
cepted since  Johannes  Muller'^s  pioneer  work  on  tumors.  If  we 
lost  this  principle,  we  should  lose  all  our  hold  on  this  domain  and 
fall  back  into  the  old  chaos  of  parasites  and  pseudoplasms. 

Let  us  now  return  to  tumors.     Their  life  and  growth  may  vary 


GENERAL  REMARKS  ABOUT  TUMORS.  661 

greatly.  In  the  first  place,  the  diseased  portion  of  tissue,  the  first 
tumor-nodule,  maj  grow  in  itself,  without  new  points  of  disease  de- 
veloping in  its  vicinity  ;  in  the  midst  of  the  tumor  itself,  from  the 
cells  collected  at  a  circumscribed  spot,  new  ones  constantly  form, 
with  a  tendency  to  develop  in  the  same  direction,  predestined  as  it 
were  forthe  type  of  development  taken  by  the  new  formation.  It 
was  formerly  supposed  that  the  distention  of  the  vessels  was  a  very 
essential  indication  of  inflammatory  neoplasia  ;  numerous  researches 
in  this  direction  have  shown  me  that  the  enlargement  and  new  for- 
mation of  vessels  in  the  development  of  the  first  tumor-nodules  are 
not  inferior  to  those  in  inflammation.  It  has  not  yet  been  proved 
that  there  is  a  softening  of  the  capillary  and  venous  walls,  as  in 
inflammation.  The  original  focus  of  disease  may  also  grow  by  new 
foci  constantly  forming  in  its  immediate  vicinity ;  an  organ  once 
diseased  in  this  way  is  rot  only  compressed  by  the  tumor,  and  its 
elements  separated,  but  it  becomes  more  and  more  diseased,  and  so 
becomes  infiltrated  and  destroyed  hy  the  tumor,  and  is  finally  trans- 
formed into  it ;  for  you  have  already  seen  that  a  neoplasia  forms  in 
normal  tissue,  the  matrix  ceases  to  grow,  and  is  partly  transformed 
into  the  new  tissue,  partly  is  destroyed.  So  in  the  fii'st  case  we  have 
an  isolated  focus  of  disease  which,  once  existing,  draw^  the  material 
for  its  increase  from  its  own  cells;  in  the  second  case  we  have  a  con- 
tinual extension  of  the  foci  of  disease.  The  first  variety,  the  to  some 
extent  pure  central  growth,  is  decidedly  less  unfavorable  to  the  organ 
diseased  than  the  latter,  the  peripheral  growth,  which,  when  it  con- 
tinues ad  Infinitum^  must  cause  comjDlete  destruction  of  the  organ, 
just  as  when  an  inflammation  or  inflammatory  new  formation  continues 
progressive.  A  combination  of  these  two  modes  of  growth  is  the  most 
unfavorable,  but  unfortunately  is  quite  frequent.  If  we  study  the  life 
of  the  tumor  itself  further,  we  find  that  the  neoplastic  tissue  does  not 
by  any  means  remain  stable,  but  is  subject  to  some  changes,  such  as 
are  also  seen  in  inflammation.  From  various  causes,  acute  and  chronic 
inflammations  may  develop  in  the  tumors,  i.  e.,  with  pain,  swelling, 
and  enlargement  of  the  vessels  ;  there  is  an  infiltration  of  small  cells 
into  the  tissue  of  the  tumor,  which  may  even  lead  to  suppuration;  this 
disease  of  a  tumor  is  the  more  frequent  the  less  its  elements  are  or- 
ganized to  a  stable  vital  tissue,  especially  the  less  its  vascular  system 
is  regulated  and  fully  organized.  Tumors  in  which  the  cell-formation 
is  so  excessive  and  progresses  so  rapidly  that  the  formation  of  vessels 
only  follows  up  the  growth  of  the  tumor  slowly  are  least  capable  of 
living ;  slight  disturbances  then  suflSce  to  impede  the  whole  process  of 
development,  or,  as  they  do  not  arrest  it  entirely,  to  cause  destruction. 
We  must  examine  somewliat  more  minutely  the  metamorphosis  of  the 


662  TUMORS. 

tissue  of  tumors  in  inflammations.  They  may  come  on  in  an  acute  or 
chronic  manner;  acute  inflammations  ara  on  the  whole  rare,  still  they 
may  be  induced  by  injuries,  blows,  or  contusions  ;  this  traumatic  in- 
flammation in  vasoiiLir  tumors  rich  in  connective  tissue  ma}'  terminate 
in  resolution  with  or  without  cicatricial  contraction,  but  frequentl}^ 
they  are  followed  b}'  more  or  less  extensive  extravasations,  gangrene, 
or  suppuration.  Chronic  inflammations  in  tumors  are  far  more  fre- 
quent, both  those  characterized  by  i^roduction  of  inflammatory  neopla- 
sia, fungous  ulcerations  with  great  vascularization,  and  those  marked 
by  torpid  ulceration.  Caseous  and  fatty  degeneration  of  the  tissue  and 
its  breaking  down  into  mucous  fluid  are  not  very  unfrequent  occur- 
rences. In  these  processes  of  softening  there  are  thrombosis  and  col- 
lateral dilatation  of  the  vessels  around  tlie  softening  point,  as  in  the 
transformation  of  a  focus  of  inflammation  to  an  abscess  or  to  caseous 
matter.  All  these  changes,  by  development  and  disease  of  the  tumor, 
may  so  complicate  its  appearance  as  to  render  it  sometimes  difficult 
at  once  to  tell  correctly,  in  any  given  case,  what  was  the  original  tissue 
of  the  tumor.  Lastly,  it  sometimes  happens  that  in  the  course  of  time 
tumors  cliange  their  anatomical  state;  for  instance,  a  connective-tissue 
tumor  which  had  long  continued  in  that  state  becomes  softer  by  raj^id 
proliferation  of  cells  and  greater  vascularization;  or,  on  the  contrary,  a 
soft  tumor  becomes  hard  from  atrophy  of  the  cells  and  cicatricial  con- 
traction of  the  connective  tissue  existing  in  the  tumor.  So  you  see 
what  an  amount  of  knowledge  and  experience  is  necessary  merely  to 
judge  correctly  in  each  case  of  these  anatomical  conditions,  wliich 
form  the  basis  of  all  our  knowledge  of  tumors;  indeed,  we  may  occa- 
sionally be  unable  to  give  to  the  object  we  have  examined  a  name 
by  which  it  may  be  simply  labeled  in  one  of  the  regular  groups ;  as 
regards  the  nomenclature  of  tumors  which  are  composed  of  various 
tissues,  we  genei'ally  choose  the  name  from  the  tissue  that  is  present 
in  the  tinnor  in  the  largest  amount. 

It  has  been  generally  agreed  to  append  cjaa  to  the  name  of  the 
affected  tissue,  to  characterize  a  tumor  histologically  ;  as  sarcoma, 
carcinoma,  etc.  There  was  no  word  tj/^a  among  the  Greeks;  it  came 
from  giving  certain  nouns  the  termination  ocj  to  make  them  verbs, 
as  :  adpf,  flesh,  oapKOo,  to  make  flesh  ;  icapKivog,  cancer,  Kapiuvoo,  to 
make  like  cancer.  The  Greeks  used  the  expression  odpKUifia,  fleshy 
tumor,  KapKivcofia,  cancer,  ulcer  (ITipj^ocrates).  Modern  nomencla- 
ture has  been  developed  from  this,  and  has  been  carried  out  by 
Virchow  with  especial  thoroughness.  The  old  Grecian  term  for  tu- 
mor in  general  is  oyKog,  bend,  bendino-,  bulk,  mass,  etc. ;  hence  Vlr- 
ehoio  has  termed  the  study  of  tumors  "  onkologie."  The  term  (pvjxa, 
(pvrov,  growth,  also  used  by  Hippocrates^  is  now  rarely  emjaloyed. 


NOMENCLATUEE   OF   TUMORS.  063 

Celsus  occasionally  designated  tumors  in  general  as  "  struma,"  but 
glandular  tumors  on  the  neck  were  more  especially  meant.  The 
English  term  "  strumous  "  what  we  call  "  lymphatic,  scrofulous." 
The  Germans  confine  the  term  "  struma  "  to  tumors  of  the  thyroid 
gland. 

I  have  little  to  say  about  the  external  gross  appearances  of  tumors. 
In  most  cases  the  growths  are  roundish  nodules,  more  or  less  distin- 
guishable, by  sight  and  feeling,  from  the  surrounding  parts.  This  is  not 
always  accurate,  however;  tubercles  also,  at  least  in  their  smallest  state, 
are  bounded  roundish  bodies,  which  I  should  no  more  class  among  the 
growths  than  I  should  papules  and  pustules  of  the  skin.  In  the  skin 
also  a  distinctly-formed  nodule  may  appear  as  a  grow  th,  just  as  an 
abscess  may  which  also  at  first  appears  as  a  nodule.  Still,  as  chronic 
inflammatory  new  formations  on  the  surface  also  frequently  appear  in 
the  form  oi  pa-pillary  proliferations  (tufts),  a  growth  forming  on  tlie 
skin  or  mucous  membrane  may  also  assume  the  papillary  form  ;  even 
the  surface  of  a  tumor,  or  a  newly-formed  cavity  containing  fluid  or 
pulp,  may  produce  papillary  proliferations.  So  you  see  that  growths 
and  inflammatory  neoplasia  are  not  accm-ately  distinguishable  by  their 
purely  external  anatomical  conditions. 

There  are  a  number  of  terms  for  difi'erent  peculiarities  of  tumors, 
which  are  frequently  used  even  now,  although  they  do  not  always 
refer  to  any  essential  point.  Thus,  a  tumor  situated  in  a  cavity,  and 
attached  by  a  pedicle,  is  called  a  polypus ;  so,  we  speak  of  nasal 
polypi,  uterine  polypi,  etc.,  but  must  add  the  histological  peculiarities 
(as  fibrous,  myxomatous,  etc.).  Growths  that  are  ulcerated  and  pro- 
ject like  a  fungus  are  called  spongy,  or  fungous.  Formerly,  if  one 
wished  to  sa}'  that  a  tumor  vv^as  very  vascular,  he  used  the  word  "  ha> 
matodes,"  while  to-day  it  is  called  "  telangiectatic,"  or  "  cavernous." 
If  a  tumor  was  very  firm  or  fibrous  (not  cartilaginous  or  bony)  it  was 
formerly  called  "  scirrhous,"  which  merely  means  "  firm,"  and  w^as 
applied  to  inflammatory  new  formations  just  as  to  cancer.  A  tumor 
was  called  medullary  when  it  had  the  color  and  consistence  of  the 
brain,  while  its  structure  might  be  that  of  sarcoma,  carcinoma,  or 
lipoma.  As  tumors  of  this  appearance  are  recognized  as  peculiarly 
malignant,  the  terms  "medullary  sarcoma,"  "medullary  carcinoma,' 
have  been  applied  to  malignant  tumors  in  general  without  regard 
to  their  structure.  Some  growths  are  colored — brown,  yellowish, 
brownish  black,  bluish  black;  this  pigmentation  may  be  due  to 
extravasations,  or  to  specific  cell-activiy.  Melanomata  or  mela- 
noses are  rare,  partly  or  entirely  black  or  brownish-black  tumors, 
with  the  structure  of  sarcoma  or  carcinoma,  and  usually  of  very  bad 
I)rognosis.     Formerly  only  these  and  similar  terms,  and  comparisons 


y(54  TUMORS. 

to  this  or  that  tissue,  Avere  used ;  it  is  enough  for  you  to  know  what 
they  mean. 

We  must  again  return  to  the  term  "  tumor."  Pure  anatomy  should 
simply  reject  this  term,  for  it  acknowledges  only  simple  or  composite 
tissue-formations  (organized  neoplasia  of  Holcitanslcy)  ;  from  a  series 
of  observations  it  can  show  how  these  structures  develop,  and  what 
becomes  of  them ;  we  shall  not  thus  arrive  at  the  term  "  tumor "  in 
the  sense  in  which  we  use  it  in  pathology.  Tumor,  or  growth,  in  the 
pathology  of  to-day,  has  a  decidedly  etiological  and  prognostic  signi- 
fication ;  as  stated  at  the  opening  of  this  section,  it  is  a  neoplasm  that 
has  not  started  from  the  same  causes  as  excite  inflammation,  but  from 
others  that  are  unknown  or  but  vaguely  suspected  ;  the  process  in  the 
organism  (local  or  general)  that  produces  tumors  is  generally  con- 
sidered different  from  inflammation  ;  some  regard  the  two  processes  as 
antagonistic  to  a  certain  extent  (we  shall  not  here  discuss  the  correct- 
ness of  this  view).  If  in  any  given  case  we  have  to  admit  that  fac- 
tors which  generally  cause  inflammation  (traumatic,  thermic,  chemical 
irritation,  etc.)  have  not  caused  the  development  of  the  tumor,  the 
case  seems  so  unusual  that  we  are  disposed  to  regard  the  growth  as  an 
unusual  organism.  This  pathologic  or  physiological  view,  as  I  might 
term  it,  was  not  formerly  maintained,  but  I  do  not  think  I  err  in  stat- 
ing that,  consciously  or  unconsciously,  it  is  held  by  most  pathologists. 
All  writers  on  tumors,  as  much  as  possible,  avoid  speaking  on  this 
point,  as  there  is  nothing  more  to  say  on  it ;  for  we  do  not  know  how 
or  where  we  shall  draw  the  dividing  line  between  chronic  inflamma- 
tion and  development  of  tumors.  So  it  is  not  possible  to  have  a 
purely  anatomical  idea  of  "  tumors,"  any  more  than  it  is  of  the  term 
"  t3^phus  ; "  to  understand  them  we  must  make  a  compromise  between 
etiology  and  pathological  anatomy.  The  etiological  expression,  "  the 
process  by  which  tumors  are  developed,"  implies  that  the  fate  of  the 
product  or  tumor  will  probably  difi'er  from  that  of  the  "  inflammatory 
neoplasia ; "  hence  we  might  say  of  tumors  that  they  do  not  bear  in 
themselves  the  conditions  for  a  typical  termination,  as  do  the  inflam- 
matory neoplasite.  I  would  not  assert  the  inflammatory  process  is  at 
all  the  opposite  of  that  by  which  tumors  are  developed ;  on  the  con- 
trary, I  believe  that  observation  teaches  that,  in  some  cases,  the  two 
processes  correspond,  especially  in  some  forms  of  chronic  inflammation 
and  sarcoma,  while,  on  the  other  hand,  acute  metritis  and  fibroid  of 
the  uterus  are  far  enough  apart,  etiologically  and  anatomically.  The 
idea  that  the  develop*ment  of  tumors  has  certain  specific  causes,  botli 
in  or  external  to  the  organism,  is  little  disputed ;  and,  when  it  is,  it  is 
hardly  in  earnest.  Virchow  asserts  that  the  development  of  tumors 
may  start  from  an  increase  of  the  inflammatory  diathesis ;  thus,  polypi 


ETIOLOGY   OF   TUMORS. 


665 


of  tlie  mucous  membraii-es  result  from  long-contimied  catarrli ;  syphilis 
induces,  first,  inflammations  ;  then,  tumors.  I  would  incidentally  re 
mark  that  I  do  not  consider  any  product  of  syphilis  a  tumor;  a  gummy 
nodule  or  a  caseous  nodule,  caused  b}^  syphilis,  either  heals  by  reab- 
sorjjtion,  or,  after  being  slit  up,  by  suppurating  and  cicatrizing,  while 
in  an  incised  tumor  this  is  exceedingly  rare.  H.  Heckle  von  Hems- 
hack  advanced  the  opposite  idea,  e.  g.,  he  says  enchondroma  of  the 
finger  is  the  mildest  expression  of  a  scrofulous  diathesis.  If  we  com- 
pare the  products  of  inflammation  with  the  histologically  more  devel- 
oped tumors,  it  must  be  acknowledged  that,  as  being  the  more  slowly 
developed  neoplasia3,  tumors  are  probably  due  to  a  feebler  local  irri- 
tation, more  alhed  to  normal  growth.  All  these  considerations  apply 
only  to  true  growths.  In  what  follows  we  shall  treat  of  these  alone. 
When  yirchoio  classes  encapsulated  extravasations  of  blood  and 
dropsies  of  serous  sacs  among  the  tumors,  he  goes  beyond  our  pres- 
ent views. 

[Heteroplastic  neoplasia,  in  relation  to  the  part  on  which  they 
are  located,  may  be  heterochronic  ;  i.  e.,  in  an  adult  a  tissue  may 
develop,  which  in  fetal  life  was  physiological,  but  which  does  not 
normally  occur  in  extra-uterine  life  ;  or  they  may  be  heterotopic  /  i.  e., 
a  tissue  analogous  to  some  physiological  type  comes  where  it  is 
never  found  normally.  iVn  example  of  this  is  the  development  in 
an  adult  of  mucous  tissue,  like  that  which  in  the  fa?tus  is  normal, 
Whartoii's  gelatine  (heterochronic  neoplasia),  or  the  formation  of 
cartilage  in  the  parotid  gland  (heterotopic). 

In  the  change  of  protoplasm  to  cells  spoken  of  (page  658),  the 
"  proliferation  "  (to  use  a  current  term)  of  granular  protoplasm,  ac- 
cording to  JSfedopiVs  investigations,  has  an  analogue  in  the  physi- 
ological development  of  the  laminated  lingual  epithelium  in  man. 
In  the  embryo  and  the  newly-born,  the  lower  la3'er,  bordering  on 
the  vessels,  consists  of  a  mass  of  granular  protoplasm,  with  no  cell- 
boundaries,  but  with  nuclei  freely  proliferating  ;  this  is  the  epithe- 
lium-forming layer,  which  toward  the  surface  forms  nuclei  sur- 
rounded by  protoplasm,  i.  e.,  sharply-bounded  cells.  According  to 
Nedopil,  the  development  of  lingual  carcinoma  takes  place  in  the 
same  way  from  the  epithelium-forming  layer,  which  to  some  extent 
assumes  its  embryonal  condition,  as  if  formed  of  homogeneous  pro- 
toplasm. 

In  continuation  of  what  was  said  (page  .559),  more  recent  studies 
of  the  history  of  development,  which  were  first  made  on  the  lower 
animals,   have   given  very   important   knowledge,   which    we   will 


666  TUMORS. 

briefly  consider  here  as  far  as  it  concerns  us.  Instead  of  the  three 
germ-layers,  we  at  present  distinguish  the  ectoblast,  the  entoblast, 
and  the  parietal  and  visceral  layers  of  the  mesoblast.  Ectoblast 
and  entoblast  are  first  formed,  and  are  the  two  primary  limiting 
layers  of  the  organism.  The  middle  germ-layers,  the  parietal  and 
visceral  mesoblast,  always  come  later,  and  form  from  eversion  or 
inversion  of  the  entoblast  ;  besides  these  germ-layers,  and  distinct 
from  them,  are  embryonal  cells  which  come  from  a  union  of  the 
original  elements,  and  are  called  mesenchymal  germs,  or  original 
cells  of  the  mesenchym.  They  serve  to  develop  between  the  epi- 
thelial limiting  layers  a  special  tissue,  the  so-called  mesenchym, 
from  which  are  derived  the  numerous  forms  of  connective  tis- 
sue, muscle-cells,  nerve-tissue,  blood-vessels,  and  lastly  the  blood 
itself. 

Adult  animals  have  the  outer  and  inner  limiting  layer  of  the 
body,  the  ectoderm  and  entoderm,  which,  developing  from  ectoblast 
and  entoblast,  have  retained  the  original  position.  But  between 
them,  as  mesoderm,  have  been  pushed  all  those  tissues  and  organs 
that  have  been  developed  from  mesenchymal  germs,  the  mesoblast, 
or  directly  from  one  of  the  germ-layers. 

From  this  account,  based  on  Hertwicfs,  it  is  evident  that  the 
former  separation  of  different  tissues,  according  to  their  develop- 
ment from  the  three  germ-layers,  cannot  be  considered  exact. 
Connective  tissue  is  not  so  geneticallj'"  distinct  from  true  epithelial 
tissue,  as  the  former  proceeds  from  mesenchymal  germs  which  have 
come  from  the  two  original  epithelial  la^^ers.  This  is  verj^  impor- 
tant in  studying  the  development  of  tumors.  In  physiology  also 
there  are  many  things  which  do  not  well  accord  with  the  former 
representation  of  the  germinal  layer  theory.  The  recently  pub- 
lished investigations  of  Sicaen  and  Masquelin,  on  the  development 
of  the  maternal  part  of  the  placenta  in  rabbits,  have  shown  that 
the  epithelial-like  cells  of  the  decidua  materna  come  from  the  pro- 
liferating connective-tissue  cells  of  the  walls  of  the  vessels  as  well 
as  from  the  true  epithelial  cells  of  the  uterine  mucous  membrane  ; 
also  that  protoplasm  masses,  originating  from  glandular  epithelium, 
enter  between  the  connective-tissue  cells  of  the  walls  of  the  vessels 
and  combine  with  the  intercellular  substance  of  the  latter  ;  lastly, 
that  true  epithelial  cells  of  the  uterine  mucous  membrane,  and  epi- 
thelium of  the  uterine  glands,  after  various  metamorphoses,  form 
haemoglobine,  the  substance  of  the  red  corpuscles,  which  may  be 
found  in  the  protoplasm  of  these  cells  as  well  as  in  the  glands,  as  a 
product  of  proliferating  cells. 

Old  observations  may  be  regarded  as  incorrect,  but  there  are 


DEVELOPMENT   OF   TUMOES.  667 

many  recent  pathological  observations  on  development  of  tumors, 
especially  of  carcinomata,  which  speak  decidedly  against  a  sharp 
division  of  tissues,  particularly  of  epithelial,  connective,  and  mus- 
cular tissues.  For  my  part,  I  think  that  there  are  indifferent  cells 
in  the  perfect  organism,  and  that  under  certain  circumstances  any 
living  cell  may  return  to  its  former  state,  where  it  was  an  indiffer- 
ent formative  cell  ;  as  a  type  of  this  lattei-,  we  have  w^hite  blood- 
corpuscles  {Recklinghausen's  wandering  cells).  All  cells  from  the 
connective-tissue  series,  the  endothelium  of  serous  membranes,  and, 
above  all,  the  fixed  connective-tissue  cells  of  the  tissues,  may  be 
regarded  as  metamorphosed  wandering  cells  or  white  blood-corpus- 
cles ;  and  it  is  easy  to  suppose  that  a  fixed  cell  in  the  connective 
tissue  may  proliferate  under  certain  circumstances,  and  produce  a 
young  cell  which  shall  have  all  the  characters  of  an  indifferent 
formative  cell — that  is,  of  a  white  blood-corpuscle.  But,  on  the 
other  hand,  we  can  describe  no  difference  between  young  formative 
cells  ;  from  which  the  so-called  heterologous  neojolasia  develop,  and 
the  derivatives  of  proliferating  connective-tissue  cells.  •  All  tissues, 
with  few  exceptions,  may  produce  such  young  cells  ;  indeed,  it  seems 
as  if  even  a  complete  cell  were  not  necessary  for  this  ;  any  proto- 
plasm may  develop  a  nucleus  which  divides  and  causes  division  of 
the  cell.  So  it  appears  that  all  cells  having  the  proi^erties  of  living 
protoplasm  may  produce  young  cells  of  more  or  less  indifferent 
character,  which  equal  white  blood-cells,  and  like  these  may  pass 
through  several  stages  of  development.  Hence  it  is  not  strange 
that  various  observers  have  witnessed  the  proliferation  of  the  endo- 
thelial cells  of  the  vessels  and  their  transmutation  to  epithelial  can- 
cer-cells ;  and  in  the  same  way  the  production  of  the  same  cells  by 
I^rolif crating  connective-tissue  corpuscles.  Endothelial  and  connec- 
tive-tissue cells  are  really  only  fixed  wandering  cells,  or  white  blood- 
or  lymph-corpuscles.  But  where  these  cells  enter  the  blood  is 
uncertain  ;  probably  they  originate  from  stabile  elements  of  the 
lymphatic  glands  and  spleen.  You  see  that  there  is  a  continuous 
circulation  in  the  development,  even  physiologically.  There  is 
nothing  strange  in  supposing  that,  in  the  development  of  tumors, 
tissue-cells  should  return  to  the  point  where  they  stood  before  the 
change  in  the  germ-layers  and  mesenchymatous  germs.  Then, 
strictly  speaking,  there  were  only  epithelial  cells  which  composed 
the  ectoblast  and  entoblast ;  hence  all  the  material  for  later  tissues 
originates  from  one  source,  primitive  epithelial  cells  ;  just  as  these 
come  from  ovum-cells  fecundated  by  the  sperm-cells,  that  is,  from 
the  cojiulation  of  two  epithelial  elements. 

Our  age  may  look  with  pride  on  the  advances  of  modern  raor- 


668 


TUMORS. 


phology,  whose  importance  is  shown  by  its  disturbance  of  former 
views,  and  by  its  contributions  in  vaiious  directions. 

Tumors  all  pass  through  the  same  course  ;  blood-vessels  form 
from  those  already  existing,  and  keep  jsace  with  the  formation  of 
actual  tumor-elements  ;  it  is  not,  as  was  formerly  supposed,  first  a 
tumor  formed  like  a  parasite,  with  vessels  subsequently  gi'owing 
into  it  from  the  periphery.  It  has  not  yet  been  determined  whether 
the  wandering  of  colorless  blood-corpuscles  is  a  part  of  this  change.] 


ETIOLOGY  OF  TUMORS.  669 

LECTURE    XLV. 

Etioloa-y  of  Tumors ;  Miasmatic  Influence.— Specific  Infection.— Specific  Reaction  of 
the  Irritated  Tissues;  its  Cause  is  always  constitutional. — Internal  Irritations- 
Ilypotlieses  as-  to  the  Character  and  Mode  of  the  Irritant  Action.— Com-se  and 
Prognosis:  Solitary,  Multiple,  Infectious  Tumors.— Dyscrasia.—Treatmcnt.— Prin- 
ciples of  the  Classification  of  Tumors. 

Let  us  now  go  more  minutely  into  tbe  etiology  of  tumors.  Here 
we  should  propose  to  find  the  differences  and  points  of  resemblance 
between  the  processes  causing  inflammatory  neoplasise  and  tumors. 
Let  us  start  with  the  causes  of  inflammation,  and  compare  them  with 
those  of  tumors.  Many  acute  inflammatory  processes  (exanthemata, 
typhus,  etc.),  and  some  chronic  ones  (intermittents,  scorbutus,  etc.), 
are  due  to  miasmata  and  contagions,  which  enter  the  body  from 
without.  I  do  not  know  any  acute  miasmatic  tumors  ;  but*  goitre 
must  be  considered  as  a  chronic  endemic-miasmatic  tumor  ;  goitre 
cannot  be  regarded  as  a  product  of  inflammation,  as  it  never  spon- 
taneously retrogrades,  suppurates,  or  shrinks  up  into  a  cicatrix  ; 
the  cause  is  a  specific  external  one,  to  which  every  one,  especially 
the  young,  is  occasionally  exposed,  who  comes  into  a  country  where 
goitre  is  endemic  ;  all  are  not  equally  disposed  to  it,  there  may  be 
an  hereditaiy  tendency  ;  infection  probably  occurs  through  the 
blood  ;  at  least,  we  cannot  well  imagine  how  the  thyroid  gland 
should  be  infected  by  local  infection.  Hence  goitre  is  probably  the 
local  expression  of  a  general  infection,  which  occasionally  evinces 
itself  in  the  whole  nutritive  state,  especially  in  anomalous  devel- 
opment of  the  skeleton  and  its  results  (cretinism).  We  may  also 
consider  leontiasis  and  Oriental  elephantiasis  as  chronic  miasmatic 
infections,  in  which  large  masses  of  nodular  fibrous  tumors  form  in 
the  skin  on  different  parts  of  the  body  ;  still,  I  acknowledge  that 
this  is  disputed  territory,  and  that  reasons  may  be  advanced  for 
classing  these  among  the  chronic  inflammatory  diseases,  instead  of 
among  tumors.  As  regards  local  infection,  or  the  transfer  of  fixed 
contagions  from  without,  we  know  that  inflammations  of  various 
kinds  may  be  thus  induced.  By  putrid  substances  only  inflamma- 
tions are  induced  ;  here  I  class,  also,  the  so-called  "  dissecting  tu- 
bercle," which  I  cannot  consider  as  a  tumor,  because  it  disappears 
spontaneously,  as  soon  as  new  infection  ceases  to  occur.  Inflam- 
mation is  excited  by  inoculation  with  pus  ;  the  character  of  the  pus 
determines  the  specific  nature  of  the  inflammation  ;  pus  may  also 
excite  a  constitutional  disease,  which  again  may  evince  itself  by 
multiple  localized  processes,  as  in  syphilis.  Can  tumors  be  hiduced 
by  inoculation  with  the  juices  of  tumors,  or  with  small  portions  of 


670  TUMORS. 

them  ?  This  is  a  disputed  point ;  I  consider  it  possible,  but  not 
proved  ;  the  difficulty  of  coming  to  a  decision  lies  in  the  fact  that 
it  is  not  allowable  to  make  such  experiments  on  men.  "When  such 
experiments  often  fail  on  the  lower  animals,  it  only  shows  that 
tumors  from  man  are  not  transferable  to  them  ;  tumors  from  beasts 
must  be  inoculated  on  beasts  of  like  species  ;  a  few  such  experi- 
ments have  been  made  by  Doutrelepond,  in  wdiich  the  inoculations 
of  carcinoma  from  dogs  on  dogs  had  no  effect. 

[Transfer  of  medullary  carcinoma  from  one  dog  to  another  is 
said  to  have  succeeded  twice  ;  after  transplantation  of  small  por- 
tions of  a  tumor  in  two  dogs,  there  were  produced  nodules  in  the 
subcutaneous  cellular  tissue,  of  which  one  ulcerated,  and  was  com- 
plicated with  infection  of  the  lymphatic  glands  ;  the  structure  of  the 
nodules  corresponded  with  that  of  the  original  tumor.  Numerous 
experiments  have  proved  that  parts  of  tumors  as  well  as  pieces  of 
tissue  of  very  young  animals  may  be  transplanted  to  other  living 
beings,  but  they  always  die  after  a  time  and  never  attain  a  tumor- 
like growth.  And  in  our  literature  there  is  no  authentic  case  of  a 
physician  infecting  himself  while  removing  a  tumor  and  acquiring 
the  same  kind  of  a  tumor  ;  while  there  are  many  instances  of  the 
transfer  of  syphilis  by  instruments,  etc. 

It  has  been  shown  that  leprosy,  a  general  disease  endemic  in 
Northei-n  Europe,  particularly  in  Norway  and  Sweden,  characterized 
by  formation  of  nodules,  may  be  transfeiTcd  by  inoculation.  Ac- 
cording to  recent  investigations  of  Armauer,  Hansen,  and  others, 
this  affection  is  due  to  a  specific  bacillus  leprae.  Sti'ictly  speaking, 
we  cannot  regard  leprous  nodules  as  tumors  any  more  than  we  could 
syphilitic  gummata.] 

At  all  events,  we  cannot  induce  a  tumor  by  inoculating  with 
pus,  which  again  seems  to  show  the  specific  difference  of  the 
products.  Perhaps  some  pathologists  may  here  answer  that  "  mol- 
luscum  contagiosum  "  is  an  example  of  tumor- juice  or  constituents 
of  tumors  being  inoculable  on  other  persons.  But  the  propriety 
of  classing  molluscum  contagiosum  among  tumors  is  disputed,  and 
instances  of  contagion  are  rare.  The  most  striking  proof  of  ^he 
distinctness  of  inflammatory  products  and  tumors  is  offered  by 
observation  of  the  local  and  general  infection,  which  we  have  in- 
numerable opportunities  of  making.  We  have  previously  said  a 
good  deal  about  progressive  and  secondary  inflammation  of  acute 
lymphangitis,  which  is  always  secondary  (deuteropathic,  Vir- 
chow),  of  the  secondary  acute  and  chronic  swellings  of  the  lym- 
phatic glands  in  acute  and  chronic  inflammations,  especially  of 
the  extremities  ;  I  then  told  you  that  I  considered  it  more  prob- 


ETIOLOGY   OF   TUMORS.  C71 

anie  that  cellular  elements  from  the  focus  of  inflammation  passed  into 
the  lymphatic  glands,  and,  by  their  specific  phlogogenous  action,  in- 
duced inflammation  in  the  glands,  which  were  analogous  to  the 
primary  peripheral  inflammations  ;  tumors  never  develop  through  such 
local  infections  from  inflammatory  foci ;  if  the  primary  inflammatory 
focus  be  removed,  the  swellings  of  the  lymphatic  glands  also  disappear. 
Similar  infectious  peculiarities  also  occur  in  many  tumors,  especially 
those  which,  like  the  inflammatory  neoplasia,  are  very  rich  in  cells; 
not  only  may  the  immediate  vicinity  be  infected,  and  numerous  new 
foci  be  formed  immediately  around  the  first  nodule,  but  very  often  the 
lymphatic  glands  are  also  afifected,  and  secondary  tumors  form  in  them, 
which  have  the  same  peculiarities  as  the  primary;  nor  are  they  any 
more  apt  to  disappear  spontaneously  than  the  primary,  even  when  the 
latter  is  removed;  on  the  contrary,  similar  tumors  then  frequently 
appear  in  other  quite  remote  parts  of  the  body — metastatic  tumors. 
Here  you  again  have  the  analogy  with  the  course  of  infection  in  in- 
flammation, as  well  as  the  specific  distinction,  for  metastatic  growths 
never  result  from  phlogistic  infection,  an3^  more  than  metastatic  ab- 
scesses in  internal  organs  do  from  infection  by  a  tumor.  Infection  is 
not  common  to  all  tumors,  although,  unfortunately,  the  majority  are 
infectious ;  these  are  called  tnallgnant^  in  contradistinction  to  the 
benign,  or  non-infectious.  It  is  difiicult  to  say  on  what  this  difference 
is  based  ;  it  is  probably  partly  due  to  the  nature  and  specific  charac- 
ter of  the  element,  in  their  easy  mobility,  and  in  the  fact  that,  like 
the  seed  of  some  of  the  lower  plants,  they  find  almost  everywhere  soil 
suited  for  their  development,  and  can  grow  in  most  tissues  of  the 
body ;  probably  it  is  also  partly  due  to  the  fact  that  the  conditions 
are  more  or  less  ftivorable  to  the  entrance  of  the  elements  of  the 
tumor  into  the  lymph  or  blood-vessels  ;  for  instance,  it  is  remarkable 
that  frequently  very  soft  tumors  (medullary  sarcoma)  consisting  almost 
entirely  of  cells,  when  surroimded  by  a  firm  connective-tissue  cajDsule, 
cause  no  infection  of  the  lymjihatic  glands ;  we  notice  the  same  thing 
in  some  large  encapsulated  abscesses.  In  regard  to  metastatic  ab- 
scesses, I  have  already  told  you  that,  according  to  my  view,  they  are 
due  to  embolism ;  we  should  have  to  seek  another  esplanation  of 
diffuse  metastatic  inflammations.  Difi"use  metastatic  tumors  are  very 
rare ;  I  should  apply  this  term  only  to  a  few  forms  of  pleural  and 
peritoneal  carcinoma  or  sarcoma.  As  regards  the  mode  of  origin  of 
metastatic  tumors,  the  actual  course  of  the  infection,  from  analogy,  it 
seems  very  probable  that  they,  like  the  secondary  tumors  of  the  lym- 
phatic glands,  are  induced  by  seed  from  the  primary  tumors,  or  from 
the  tumors  in  the  lymphatic  glands.  I  acknowledge  I  am  much  in- 
clined to  this  supposition.     Although  I  could  not  formerh'-  believe  that 


672 


TUMORS. 


the  cells  from  a  focus  of  inflammation  or  from  a  tumor  could  be  as  in- 
dependent as  tliistle-down,  still,  I  think  that,  with  our  present  knowl- 
edge about  the  indej)endent  life  of  pathologically-neoplastic  cells, 
there  can  be  no  doubt  of  the  possibility  of  such  a  process.  Quite  re- 
cently an  observation  has  been  published  which  is  a  new  proof  of  the 
great  independence  of  the  cells  of  the  rete  Malpighii ;  I  mean  the  epi- 
dermis transplantation  of  Meverdin,  which  has  been  so  often  men- 
tioned. This  renders  it  even  more  probable  than  formerly  that  detached 
cellular  elements  of  a  neoplasm,  carried  to  some  other  part  of  the  body 
by  the  blood  or  other  fluids,  may  there  continue  its  growth.  Although, 
on  the  first  development  of  a  tumor,  as  on  the  occurrence  of  an  in- 
flammatory new  formation,  the  lymphatic  vessels  are  partly  closed, 
and  may  be  filled  with  cells,  still,  subsequently,  from  comj^ression, 
lymphatic  and  vascular  thrombi  may  form,  into  which  specific  tumor- 
elements  enter,  and  small  particles  of  thrombi,  which  might  form 
dui'ing  the  softening  of  the  tumor,  may  enter  the  circulation,  become 
attached  at  difl"erent  places,  and  form  new  tumors.  In  veins,  the  for- 
mation of  such  thrombi  filled  with  specific  tumor-elements  has  actually 
been  observed,  and,  at  the  same  time,  analogous  tumors  have  been 
found  in  the  branches  of  the  pulmonary  artery.  It  is  important  to 
remember  that  metastatic  tumors,  like  metastatic  abscesses,  arc  cliiefly 
found  in  the  lungs  and  liver,  except  in  cases  where  direct  metastasis 
is  very  easy,  as  in  pleural  tumors,  which  develop  as  a  result  of  primary 
mammary  tumors,  as  in  hepatic  tumors  found  with  those  of  the  intes- 
tines or  stomach ;  in  these  cases  a  direct  wandering  of  tissue-elements 
through  the  lymphatic  vessels  is  very  possible.  On  this  point  there 
is  still  much  room  for  investigation,  which,  I  think,  will  meet  great 
results.  As  we  have  already  seen,  the  products  of  acute  inflamma- 
tion mostly  have  a  pyrogenous  action ;  those  of  chronic  inflammation 
lack  this  peculiarity  almost  as  much  as  do  those  of  tumors ;  fever 
only  occurs  in  the  latter  when  there  is  disintegration  of  the  neoplasia, 
and  the  products  of  the  disintegration  enter  the  circulation;  more 
frequently,  infection  with  such  excreted  matters  shows  itself  in  chronic 
inflammation  in  tumors  by  a  general  cachectic  state,  especially  by  dis- 
turbance of  the  general  nutrition. 

If  we  consider  what  has  been  said  about  the  contagiousness  of 
tumors,  Ave  see  that  there  is  some  probability  of  their  transfer  from 
one  person  to  another,  though  it  is  not  proved ;  but  there  can  be  no 
doubt  that  the  lymphatic  glands  and  other  organs  may  be  gradually 
infected  by  various  kinds  of  tumors. 

As  regards  the  efi^ect  of  taJcing  cold  locally  and  generally  as  a 
cause  of  inflammation,  there  are  no  observations  which  would  justify 
us  in  referring  tumors  to  a  similar  cause.  I  do  not  know  that  any  one 
has  ever  asserted  and  proved  that  tumors  result  from  catching  cold. 


ETIOLOGY  OF  TUMORS.  673 

Views  vary  greatly  about  mechanical  and  chemical  influences  aa 
causes  of  tumors.  Various  as  the  irritations  may  be,  and  much  as 
they  have  been  experimented  with,  in  no  single  case  has  a  tumor  been 
caused  intentionally  by  mechanical  or  chemical  irritation ;  inflamma- 
tory new  formations  thus  developed  do  not  long  outlast  the  external 
Irritation.  Wherever  and  however  we  apply  such  mechanical  and 
chemical  irritants,  we  only  induce  inflammations  ;  if  there  be  any  spe- 
cific mechanical  and  chemical  irritation  (I  mean  one  acting  on  the  or- 
ganism from  without,  not  starting  from  the  tumor),  i.  e.,  one  from 
whose  action  a  tumor  must  develop,  it  is  at  present  unknown.  Then 
the  question  arises  whether  there  are  any  reasons  which  render  it 
absolutely  necessary  to  assume  such  mechanical  and  chemical  irrita- 
tion outside  of  the  organism.  I  cannot  agree  to  this.  It  is  true  there 
are  many  cases  where  a  tumor  forms  after  a  blow,  kick,  or  injury,  but 
the  number  of  such  cases  is  very  small  in  proportion  to  those  where, 
after  similar  causes,  there  is  acute  traumatic  inflammation,  with  a  tvpi- 
cal  course,  or,  if  the  irritation  be  continued,  chronic  inflammation  also 
with  typical  course.  We  must  regard  this  also  as  a  rule :  if  a  porter 
gets  a  thickening  of  the  skin,  wdth  new  mucous  bursa  imder  it,  on  the 
spinous  process,  or  if  he  gets  an  ulcer  at  the  same  point,  it  is  to  some 
extent  a  normal  result,  they  are  products  of  a  chronic  inflammatorv 
irritation,  and  disappear  as  soon  as  the  irritation  ceases ;  but  if  from 
the  same  causes  a  person  gets  a  fatty  tumor,  which  does  not  disap- 
pear, but  even  continues  to  grow  when  the  irritation  ceases,  we  can- 
not here  regard  the  irritation  as  specific,  but  must  seek  the  peculiarity 
in  the  affected  part.  Previously  in  general  and  local  infections  we 
recognized  the  specific  effects  of  irritation,  now  we  must  also  acknowl- 
edge that  there  is  a  specific,  qualitative,  abnormal  reaction  of  the  tis- 
sue. Virchoio  and  0.  Weber  especially  have  maintained  that  exter- 
nal irritation  always  plays  an  important  rdle  in  the  development  of 
tumors  ;  this  follows  undoubtedly  from  the  fact  that  primary  tumors 
are  most  frequent  at  points  most  subject  to  external  irritation.  Sta- 
tistics show  that  the  most  frequent  seat  of  tumors  is  the  stomach, 
then  the  portio  vaginalis  uteri,  then  face  and  lips,  then  the  mammary 
glands,  rectum,  etc.  But  the  reason  for  the  development  of  tumors, 
and  not  of  chronic  inflammation  in  such  cases,  must  be  a  specific  dis- 
position of  these  parts  in  certain  persons.  Individuals  who  drink 
much  spirits  usually  have  gistric  catarrh ;  if,  among  one  thousand 
topers,  one  or  even  ten,  instead  of  catarrh,  had  cancer  of  the  stomach, 
he  should  be  considered  as  an  abnormal  subject,  when  compared  with 
the  mass  who  do  not  have  it.  Up  to  this  point  I  agree  entirely  with 
Virchow^  who  speaks  as  follows :  "  Although  I  cannot  tell  in  what 
particular  way  an  irritation  must  occur,  to  induce  a  tumor  in  some 
44 


6Y4  TUMORS 

g-iven  case,  while  in  another  case,  perhaps  under  apparently  similar 
circumstances,  it  merely  excites  simple  inflammation,  still  I  have  com- 
municated a  series  of  facts  which  teach  that,  in  the  anatomical  compo- 
sition of  diflferent  parts,  certain  continuous  disturbances  may  exist 
which  interfere  wdth  the  occurrence  of  regulating  processes,  and 
which,  from  an  irritation  that  at  another  spot  would  have  induced  a 
simple  inflammation,  excite  an  irritation  from  which  the  specific  tumor 
is  developed."  Among  facts  "  which  teach  that,  in  the  anatomical  com- 
position of  diflferent  parts,  certain  continuous  disturbances  may  exist " 
which  dispose  to  development  of  tumors,  Virchow  mentions  advanced 
afje.  It  is  perfectly  true  that  certain  forms  of  tumors  are  very  fre- 
quently found  on  particular  parts  of  the  body  in  old  persons,  e.  g.,  can- 
cier  of  the  lip.  Thiersch  calls  attention  to  the  fact  that  in  the  lips  of 
old  men  the  connective  tissue  is  often  so  much  atrophied  that  the  epi- 
thelial tissues  (sebaceous,  sweat,  and  mucous  glands,  hair-follicles,  etc.) 
become  very  prominent,  and,  as  it  were,  receive  the  preponderance  of 
nutrition ;  that  hence  irritation  shows  itself  chiefly  in  the  proliferation 
of  these  epithehal  formations,  and  that  this  explains  the  frequent  oo- 
ciirrence  of  epithelial  cancer  in  the  lips  of  old  men.  I  fully  recognize 
the  shrewd  combination  of  these  observations,  but  I  must  add  that 
advanced  age  is  just  as  much  a  general  as  a  local  pecidiarity  of  the 
body.  It  is  also  stated  by  Virchow  that  places  which  have  been  the 
seat  of  an  inflammatory  disease,  which  has  left  the  part  w^eakened, 
also  cicatrices,  furnish  foci  for  the  development  of  tumors.  This  is 
undoubtedly  true ;  but  if  we  compare  the  innumerable  cases  where 
simple  chronic  inflammation  occurs  in  parts  that  have  been  acutely 
diseased,  and  where  simple  ulceration  occurs  in  cicatrices,  the  cases  in 
which  tumors  occur  at  such  points  appear  very  small,  and  it  must  be 
acknowledged  that  in  these  few  cases  we  may  assume  a  specific  pre- 
disposition which  leads  to  formation  of  tumors.  The  same  holds 
good  for  the  fact  that  tumors  are  particularly  apt  to  form  in  organs 
which  complete  their  formation  and  development  late  in  life ;  here 
Virchoio  classes  the  articular  ends  of  the  bone  (which,  however,  are 
the  seat  of  tumors  much  more  rarely  than  of  chronic  inflammations), 
the  mammary  glands,  the  uterus,  ovaries,  testicles,  etc.  While  fully 
recognizing  the  exercise  of  observation  and  brilliant  ideas  by  which 
it  is  attempted  to  prove  the  purely  local  disposition  to  development 
of  tumors,  I  cannot  consider  the  proof  as  at  all  convincing,  but  re- 
main of  the  opinion  that  there  is  just  as  much  a  specific  predisposition 
to  the  development  of  tumors  as  there  is  to  chronic  inflammations^ 
with  proliferation  of  the  inflammatory  new  formation^  with  suppura- 
tion^ with  caseous  degeneration^  etc. 

To  what  has  just  been  said  we  must  add  that  we  cannot  always 


ETIOLOGY  OF  TUMORS.  675 

detect  a  local  external  irritation  when  a  tumor  is  developed  any  more 
than  we  can  alwaj'S  do  so  in  local  disease  in  a  scrofulous  patient. 
Wliile  referring  you  to  what  has  been  said  on  the  etiology  of  chronic 
inflammations,  I  would  remark  that  in  regard  to  primary  tumors  we 
may  assume  in  many  cases  that  there  are  also  specific,  so-called  inter- 
iial  irritations  developing  in  the  body  itself.  Most  pathologists  agree 
to  this,  but  they  consider  the  mode  of  origin  and  development  of 
such  irritations  as  being  different.  Virchow  teaches  that  the  local 
disease  must  have  a  local  cause,  and  assumes  that  at  the  point  of  dis- 
ease there  are  certain  local  conditions  of  debility.  If  this  were  so,  we 
should  have  to  assume  a  specific  local  debility  for  the  most  different 
disturbances  of  nutrition  and  for  formation  of  tumors.  Itindfleisch 
speaks  very  decidedly  of  internal  irritation  as  follows :  "  By  the 
change  of  substance  in  the  tissues,  certain  excretive  substances  are 
constantly  being  formed,  which  must  gradually  be  passed  off  from  the 
tissues  and  organs  in  which  they  form,  as  well  as  from  the  fluids  of 
the  body  at  large,  in  order  that  the  life  of  the  individual  may  be  un- 
disturbed. These  bodies  have  their  chemical  position  between  the 
organopoietic  bodies  on  the  one  hand  and  the  excreted  matter  of  the 
kidneys,  skin,  and  lungs,  on  the  other ;  thus  they  fall  into  the  great 
gap  that  exists  in  organic  chemistry  at  this  point ;  they  are  different 
for  the  different  tissues,  and  on  this  difference  depends  the  variety  of 
■  pathological  new  formations.  If  they  are  transformed  and  excreted 
normally  they  collect  first  at  the  point  of  their  origin,  then  in  the 
fluids  of  the  body,  and  this  collection  is  the  immediate  cause  for  the 
excitement  of  that  progressive  process  which  begins  with  multiplica- 
tion of  cells  in  the  connective  tissue,  and  ends  with  the  development 
of  tubercles,  cancer,  cancroid,  fibroids,  lipomata,  etc."  I  can  entirely 
agree  with  this  hypothesis,  but  must  add  that  it  seems  an  error  to 
suppose  that  we  here  speak  chiefly  of  local  processes.  The  produc- 
tion of  bile  and  urine  is  also  a  local  process ;  for  them  to  be  produced 
in  such  quantities  and  of  such  a  quality  as  they  are  depends  not  only 
on  the  glandular  organs,  but  on  the  entire  organism  to  such  an  ex- 
tent that  we  must  seek  the  original  causes  of  the  secretion  of  urine 
and  bile  not  only  in  the  blood,  but  even  more  remotely,  even  in  pe- 
culiarities of  origin,  as  far  back  as  Adam,  if  you  please.  In  the  same 
way,  I  think  that  the  original  causes  for  the  local  requirements  for  the 
development  of  tumors  must  be  sought  in  specific  pecuUarities  of  the 
individual  organism ;  in  the  same  way  we  speak  of  a  scrofulous  or  tu- 
berculous person,  meaning  the  pathological  race,  as  it  were,  to  which 
the  individual  belongs. 

I  must  lastly  add  that  the  supposition  that  the  cause  of  disease, 
the  irritation  inducing  the  tumor,  develops  local  y,  where  the  tumoj 


6V6  TUMORS. 

afterward  forms,  is  as  purely  hjrpothetical  as  any  that  has  yet  been 
advanced.  Let  us  take  arthritis  as  an  analogy :  ZalesJci  induced  the 
most  typical  arthritis  in  a  goose  by  ligating  the  ureters ;  an  articular 
disease  resulting  from  disturbance  of  the  function  of  the  kidneys . 
Possibly  tumors  might  just  as  well  develop  in  any  tissue  from  dis- 
turbance of  the  hepatic  function !  Very  many  things  are  possible. 
We  know  nothing  certain  on  this  point,  and  move  entirely  in  hypoth- 
eses. For  my  part,  I  find  it  just  as  allowable  to  assume  a  diathesis 
here,  as  in  scrofula,  arthritis,  etc. ;  that,  partly  from  unknown,  partly 
from  known  causes  of  general  nutrition  and  ordinary  conditions  of 
life,  abnormal  matters  proceed,  which  have  a  specific  irritant  action 
on  this  or  that  part  of  the  body,  analogous  to  that  of  certain  drugs. 
Lastly,  if  to  this  we  add  that  the  diathesis  for  production  of  tumor  is 
hereditary,  although  not  to  such  an  extent  as  the  chronic  inflammatory 
diathesis,  the  doctrine  of  weakness  localized  in  certain  systems  of  tis- 
sue, or  certain  parts  of  the  body,  seems  entirely  untenable.  There  is 
certainly  a  local  cause  for  the  members  of  one  family  having  large 
noses ;  in  proportion  to  the  face,  they  have  grown  larger  than  in  other 
men,  still  the  large  nose  of  the  father  cannot  descend  directly  to  the 
son,  it  can  only  be  inherited  from  the  father  through  the  spermatozoa, 
and  there  the  original  cause  is  to  be  sought ;  all  peculiarities  that  de- 
scend by  inheritance  are  unquestionably  to  be  termed  constitutional. 

I  have  now  occupied  you  some  time  with  reflections  which  some 
of  you  may  consider  very  tedious ;  they  will  ask  me.  Of  what  use 
are  these  things  in  practice  ?  Then,  unfortunately,  I  must  acknowl- 
edge that  practice  pays  little  attention  to  them,  because  they  are  so 
hypothetical.  Those  of  you  to  whom  such  ideas  as  we  have  just 
spoken  of  do  not  occijr,  I  advise  to  pay  no  further  attention  to  them ; 
not  to  be  obliged  to  speculate  as  to  the  final  causes  of  things  is,  in 
a  certain  sense,  an  enviable  quality. 

For  convenience,  let  us  comprise,  in  a  few  short  propositions,  what 
we  have  said  regarding  the  etiology. 

Tumors,  like  inflammatory  neoplasire,  result  from  irritation  of  the 
tissue  ;  the  diff'erence  in  the  causes  lies :  1.  In  the  specific  quality  of 
the  irritation.  Infection  of  healthy  tissue  about  a  tumor,  neighboring 
lymphatic  glands,  etc.,  is  considered  sufiicient  proof  of  this.  It  is 
supposed  that,  under  some  unknown  circumstances,  this  specific  irri- 
tant may  be  formed  locally  {Mindfleisch).  I  think  that,  partly  as  a 
result  of  hereditary  predisposition,  partly  from  a  developed  tendency, 
that  is,  where  there  is  a  diathesis,  we  may  imagine  the  formation  of 
materials  in  the  fluids  of  the  body,  which  shall  have  a  specific  irritant 
action  on  one  or  other  tissue.  2.  Any,  usually  an  inflammatory,  irri- 
tation may  excite  a  tumor,  if  the  irritated  tissue  is  specifically  disposed 


PROGNOSIS  AND  COURSE  OF  TUMORS.  677 

for  the  development  of  growths.  Virchoio,  0.  Weber,  Eindfleisc\ 
and  others,  assume  that  such  specific  peculiarities  are  entirely  local 
and  limited  to  an  accidentally  irritated  part  of  the  body,  or  to  a  cer- 
tain system  (bones,  skin,  muscle,  nerves,  etc.).  I  cannot  imagine  the 
localization  of  such  specific  peculiarities ;  hence,  even  with  this  h}7)oth- 
esis,  it  seems  probable  that  the  apparent  local  specific  peculiarities 
are  due  to  the  intimate  relations  of  the  entire  organism. 

From  this  representation  you  may  see  that  the  different  views 
only  differ  in  the  purely  hypothetical  part.  If  I  entered  into  the  sub- 
ject more  fully  than  seemed  necessary  for  these  lectures,  it  was  be- 
cause this  very  important  branch  of  general  pathology  has  lately 
been  so  exhaustively  and  excellently  treated  of  by  Virchow,  0. 
Weber,  Hindfleisch,  LiXcke,  Thiersch,  Klebs,  Waldeyer,  and  others, 
that  I  considered  it  necessary  to  develop  more  fully  those  parts  of  my 
views  where  I  differed  from  these  authors,  whose  excellent  writings  I 
cannot  too  strongly  recommend  for  your  study. 


In  regard  to  the  prognosis  and  course  of  tumors,  from  what  has 
been  said  you  may  infer :  1.  That  they  seldom  recover  spontaneously, 
nor  are  they  accessible  to  medicines ;  and,  2.  That  they  are  partly  in- 
fectious, partly  not  so.  The  latter  point  is  particularly  striking  to 
unprejudiced  observation.  There  are  some  tumors  which  do  not  re- 
turn after  extirpation,  and  others  that  not  only  return  in  the  cicatrix, 
but  come  in  the  neighboring  lymphatic  glands  and  also  in  internal  or- 
gans, as  already  remarked.  The  former  have  for  ages  been  called 
benignant,  the  latter  malignant  or  cancerous.  This  observation  is  so 
simple  that  it  would  seem  merely  necessary  to  study  exactly  the 
peculiarities  of  one  or  other  form  of  tumor,  to  arrive  at  an  accurate 
prognosis.  But  accurate  clinical  and  anatomical  study  did  not  lead 
to  this  desired  simple  result  of  this  dualism,  but  it  showed  that  the 
latter  did  not  exist,  that  the  conditions  were  more  complicated.  After 
an  exhaustive  anatomical  study  and  description  of  benignant  and 
malignant  growths,  they  were  examined  under  the  microscope  and  in 
the  retort ;  it  was  thought  that  the  characteristic  marks  had  been 
found  now  in  one  point  now  in  another,  and  soon  one  discovery  after 
another  proved  erroneous :  it  was  thus  shown  that  an  antithesis  of 
absolute  malignancy  and  benignancy  did  not  exist  in  the  sense  meant, 
and  that  it  was  necessary  to  distinguish  not  only  solitary,  multiple, 
and  infectious  tumors,  but  that  a  scale  must  also  be  made  in  the  grade 
of  infectiousness.  We  must  investigate  this  more  closely.  We  3all 
a  tumor  solitary  Avhen  only  one  occurs  in  the  body  and  causes  purely 
local  symptoms ;   they  are  usually  growths  consisting  of  any  fullv- 


678  TUMORS. 

developed  tissue — fibruma,  chondroma,  osteoma,  etc.  We  speak  of 
multiple  tumors  when  a  series  of  similarly-organized  growths  occur 
only  in  one  certain  system  of  tissue ;  for  instance,  when  numerous 
chondromata  occur  only  on  bones,  or  numerous  lipomata  only  in  the 
subcutaneous  cellular  tissue,  or  many  fibromata  only  in  the  skin,  etc. 
As  generally  acknowledged,  there  is  at  the  same  time  a  predisposition, 
which  Virchow  regards  as  purely  local,  but  which,  as  already  stated, 
I  must  consider  constitutional.  In  general,  we  may  say  that  aU  sorts 
of  tumors  may  occur  as  solitary  or  multiple,  although  the  latter  is 
very  rare  in  some  forms  of  tumors.  We  apply  the  term  infectious  to 
a  tumor  which  not  only  grows  into  the  parts  around  it,  infiltrating 
them  and  thus  constantly  growing  by  apposition  of  new  foci,  but 
which  may  also  infect  the  next  lymphatic  glands  and  finally  other  or- 
gans. In  this  respect  there  are  very  great  diiferences :  in  some  tumors 
the  infection  extends  regularly  only  to  the  next  lymphatic  glands 
(carcinoma  of  the  lips  and  face)  ;  in  other  cases  from  that  point 
it  extends  farther,  especially  to  internal  organs  (carcinoma  of  the 
breast) ;  lastly,  infection  of  the  entire  body  with  metastatic  tumors, 
without  infections  of  the  lymphatic  glands,  sometimes  occm-s  (some 
forms  of  sarcoma).  Moreover,  the  rapidity  with  which  infection  fol- 
lows, varies  greatly.  If  we  examine  the  conditions  under  which  in- 
fectious tumors  develop,  and  their  anatomical  structure,  we  shall  see 
that  they  occur  especially  in  advanced  age,  about  equally  in  men  and 
women,  and  particularly  often  in  certain  organs ;  that  the  age  of  child- 
hood is  disposed  to  infectious  growths,  especially  to  malignant  sar- 
comata, while  in  youth  and  the  first  years  of  adult  age  very  few  tu- 
mors of  any  kind,  and  especially  few  malignant  tumors,  develop. 
Mode  of  life,  good  or  bad  food,  povertj^  riches,  character,  nationality, 
and  cultivation,  appear  to  have  no  special  influence  on  the  develop- 
ment of  tumors  generally ;  nor  can  we  recognize  any  specific  influence 
of  these  powers  on  infectious  tumors.  The  study  of  the  anatomical 
structure  of  tumors  has  been  pursued  with  great  zeal  of  late,  and  it 
appears  that  a  large  number  of  malignant  growths  have  characteristic 
macroscopic  and  microscopic  peculiarities,  but  that  a  correct  progno- 
sis cannot  always  be  based  on  them  ;  in  general  we  may  say  that 
they  are  usually  very  vascular  tissue  formations,  disposed  to  ulceration, 
and  in  their  course  proving  to  be  infectious.  As  it  is  most  probable 
that  the  infection  results  from  the  locomotion  of  specific  tumor-ele- 
ments, some  of  the  factors  relative  to  reabsorption  may  here  have 
some  eficct.  The  quantity  of  blood  and  lymphatic  vessels  in  the 
tumor  and  its  immediate  vicinity,  the  conditions  influencing  opening 
and  closvire  of  these  passages,  and  the  activity  of  the  circulation  gen* 
erally,  are  to  be  considered. 


TREATMENT   OF  TUMORS.  g-^g 

Infectious  tumors  are  usually  at  first  solitary,  very  seldom  multiple  iD 
tlie  sense  above  indicated.  Tumors  that  are  multiple  from  the  start  are 
rarely  infectious.  When  we  use  the  terms  dangerous,  malignant,  and 
infectious,  as  synonymous,  we  do  so  without  regard  to  the  locality 
where  the  tumors  are  developed.  A  soHtary  benignant  tumor  in  the 
brain  is  always  malignant,  from  its  locality  ;  an  infectious  tumor  at  the 
same  point  possibly  never  goes  bej-ond  local  infection,  as  it  soon 
proves  fatal.  All  these  things  are  to  be  carefully  weighed,  if  we 
would  obtain  clear  ideas  on  these  points. 

Tumors  are  not  always  to  be  termed  infectious  (malignant,  cancer- 
ous) because  of  a  return  at  the  point  of  operation.  In  this  case  it  ia 
very  important  to  decide  whether  the  recurring  tumor  has  started 
from  portions  of  the  original  tumor,  that  have  been  left  at  the  time 
of  operation  (continuous  recurrence,  Thiersch),  or,  possibly  years  after 
a  perfect  operation,  a  new  tumor  has  occurred  from  similar  causes  in 
the  cicatrix  or  in  its  vicinity  (regional  recurrence).  If  the  point  of 
operation  remains  free,  and,  after  the  operation,  swellings  of  the  lym- 
phatic glands,  of  the  same  nature  as  the  extirpated  tumor,  appear,  or 
if,  under  similar  circumstances,  without  swelling  of  the  lymphatic 
glands,  growths  occur  in  other  organs,  it  may  be  considered  certain 
that  these  lymphatic  glands  and  other  organs  were  already  infected 
at  the  time  of  operation,  although  this  may  not  have  been  susceptible 
of  proof  on  examination. 

When  a  person  is  infected  from  a  tumor,  we  term  it  a  dyscrasia^ 
just  as  we  do  when  one  is  infected  from  a  focus  of  inflammation.  In 
such  persons  foreign  materials  circulate  in  the  fluids  of  the  body, 
inducing  in  them  a  pathological  condition.  In  infectious  tumors  this 
dyscrasia  displays  itself  by  general  disturbance  of  the  nutrition — ema- 
ciation, marasmus ;  how  soon  and  how  extensively  this  shall  occur 
depends  very  essentially  on  the  seat  of  the  tumor  and  its  peculiarities 
(softening,  becoming  gangrenous,  ulceration,  bleeding,  etc.)  as  well 
as  on  the  strength  and  age  of  the  patient. 


About  the  treatment  of  tumors  in  general  I  shall  here  merely 
mention  that  they  are  only  curable  by  removal  from  the  body,  whether 
by  the  knife,  ligature,  ecraseur,  caustic,  or  any  other  means.  The 
removal  of  intense  and  rapidly-infecting  tumors  is  usually  merely  a 
means  of  prolonging  life  or  of  alleviating  the  suS"erings  of  the  patient ; 
tumors  that  cannot  be  operated  on  we  can  only  treat  symptomati- 
oally,  to  ease  the  patient.  I  shall  speak  of  the  indications  for  opera 
tin  or  when  treating  of  the  diS"erent  forms  of  tumors. 


680  TUMORS. 

Now,  when  passing  to  the  consideration  of  the  diflPerent  forms  of 
tumors,  we  shrink  from  the  mass  of  material  before  us.  We  require 
a  leading  principle  to  enable  us  to  arrange  the  various  forms  of  tumors 
which  differ  so  much  anatomically  and  clinically,  and  to  consider  them 
in  their  relations  to  each  other  and  to  the  organism  at  large.  The 
principles  on  which  tumors  have  been  classed  have  for  ages  been  just 
as  different  as  those  on  which  diseases  generally  have  been  and  are 
still  divided.  None  of  the  classifications  of  disease  proposed  so  far 
have  held  their  place  long.  Medicine  is  now  taught  in  various  groups 
of  smaller  systems,  and  the  principles  for  forming  such  groups  are 
chosen  for  various  reasons.  Before  pathological  anatomy  was  de- 
veloped, some  prominent  symptom  was  taken ;  hence  we  still  have  in 
medicine  the  terms  icterus,  apoplexy,  etc.,  to  denote  certain  diseases ; 
in  the  same  w'ay,  as  3'ou  know,  we  have  tumors  designated  "  polypus, 
scirrhus,  lupus,  fungus,  carcinoma,"  etc.  As  soon  as  the  symptoms 
icterus  and  apoplexy  were  analyzed  and  found  to  depend  on  very 
different  anatomical  causes,  these  terms  were  banished  and  replaced 
by  others  denoting  the  anatomical  condition.  The  pathologico-ana- 
tomical  arrangement  of  disease,  as  proposed  by  Hokitanslcy,  for  in- 
stance, is  undoubtedly  scientific,  as  is  the  system  of  general  pathology 
of  VircJiow ;  still,  neither  of  them  is  accepted  without  reserve  by 
clinical  teachers.  It  was  desired  to  dinde  diseases  according  to  their 
peculiar  nature  and  cause  ;  but  Schonbehi's  attempt  to  found  a  system 
with  this  idea  failed,  for  our  knowledge  of  the  causes  and  nature  of 
disease  is  not  sufficient  fully  to  carry  out  the  plan.  What,  then,  is  to 
be  done  ?  Practical  medicine  and  surgery  start  partly  from  the  ana- 
tomical system,  consider  this  as  generally  known,  and  use  it  for  sub- 
dividing more  extended  descriptions  of  disease  foimded  on  an  etiolo- 
gical, prognostic,  symptomatological,  or  physiological  basis.  It  would 
certainly  not  be  unscientific  even  now  to  write  a  monograph  on  icterus 
or  apoplexy — then  the  anatomical  conditions  would  come  in  the  second 
rank ;  pathological  anatomy  is  used  as  any  other  aid  to  science,  as  chem- 
istry, physics,  etc. ;  we  always  try  to  bear  in  mind  that  the  object  in 
fathoming  the  whole  process  of  disease  lies  not  in  simply  fathoming 
the  morphological  conditions ;  it  is  desirable  to  understand  not  only 
the  anatomical  change,  but  also  the  mode  and  causes  of  the  physiologi- 
cal disturbances.  It  would  be  decidedly  unscientific  in  tj'phus,  even 
if  a  number  of  palpable  changes  were  found,  to  admit  nothing  except 
the  peculiar  intestinal  inflammation  ;  we  may  regard  this  as  something 
of  the  past.  Could  we  group  all  diseases  from  an  etiological  point  of 
view,  it  would  be  an  immense  advance ;  then  pathological  physiology 
would  take  the  place  of  pathological  morphology,  while  with  our 
present  knowledge  we  are  quite  proud  if  we  accurately  recognize  the 


I 


CLASSIFICITIOX   OF  TUMORS.  681 

morphological  development  of  the  morbid  product,  for  we  can  then 
Bay  that  we  know  at  least  one  important  factor  of  the  pathological 
process.  In  fact,  we  know  no  more  about  normal  development ;  it  will 
be  long  before  we  understand  the  physiology  of  the  growing  foetus. 

After  these  considerations,  we  may  not  be  any  more  particular 
about  the  classification  of  tumors  than  we  are  in  the  other  diseases ; 
we  must  see  that  there  will  be  a  difference  according  as  we  choose 
etiology,  symptomatology,  prognosis,  or  anatomy,  as  the  principle  for 
di\asion.  Formerly,  surgeons  preferred  classing  tumors  according  io 
the  prognosis  of  the  individual  forms,  into  malignant  and  benignant, 
and  adding  a  few  subdivisions  according  to  the  appearance  or  con- 
sistence of  the  tumor  or  the  looks  of  its  cut  surface.  This  was  enough 
as  long  as  observations  on  these  subjects  were  made  in  the  gross,  and 
the  surgeon  made  no  great  claims  in  prognosis.  But  the  more  accu- 
rate the  observations  at  the  bedside,  and  the  more  varied  the  forms 
in  which  the  neoplastic  tissue  appeared  under  the  microscope,  the 
more  impossible  it  became  to  make  the  anatomical  peculiarities  of 
tumors  agree  with  the  old  views  of  malignancy  and  benignancy. 
While  now  most  surgeons  and  pathological  anatomists  gave  up  the 
idea  of  letting  the  prognosis  play  a  part  in  the  classification,  and  since 
Johannes  MiXUer's  works  on  this  subject  turned  their  attention  to 
working  out  the  finer  anatomy  and  developmental  layers  of  the 
pseudo-plasms,  I  still  made  some  attempts  to  retain  the  clinically- 
prominent  symptoms  of  benignancy  and  malignancy  in  a  more  en- 
larged form,  as  a  basis  for  the  classification  of  tumors,  and  under 
these  to  arrange  the  modern  acquisitions  of  pathological  histology. 
Either  I  did  not  find  the  correct  form  and  expressions  for  my  ideas,  or 
the  task  I  tried  was  impossible,  for  I  remained  alone  with  my  ideas  on 
this  subject,  and  have  abandoned  them.  Although  I  am  still  of  the 
opinion  that  we  should  not  cease  seeking  for  a  phj'siological  (etio- 
logical-prognostic,  clinical),  recognition  of  the  process  on  which  the 
formation  of  tumors  depends,  and  although  I  should  even  now  esteem 
a  division  of  tumors  on  physiological-genetic  principles  more  highly 
than  one  on  anatomical-genetic  principles  (which  was  Yirchow's  idea 
m  his  wonderful  classic  work  on  tumors),  still  I  abandon  further  at- 
tempts in  this  direction,  and  follow  the  anatomical  principles  in  clas- 
sification, passing  gradually  from  tumors  formed  of  simple  tissues  to 
those  formed  of  more  complicated  tissues. 

Lastly,  I  must  mention  that  I  voluntarily  and  intentionally  limit 
my  lectures  to  those  cases  of  tumors  which,  in  the  commencement  of 
the  disease  at  least,  are  seated  in  parts  of  the  body  belonging  to  sur- 
gery. This  limitation  is  not  so  important  as  it  seems ;  we  may  even 
Bay  that  the  peculiar  course  of  tumors  can  only  be  studied  in  its 


682  TUMORS. 

purity,  when  they  are  located  in  parts  where  they  do  not  directly 
endanger  life;  for  the  symptoms  which  they  cause  when  in  liver, 
stomach,  or  brain,  are  not  those  due  to  the  tumors  themselves,  but  are 
chiefly  disturbances  of  function  in  the  aflfected  organ.  If  every  typhus 
was  accompanied  oy  fatal  intestinal  haemorrhage  or  perforation  of  the 
intestine,  we  should  never  have  a  pure  representation  of  the  disease 
proper,  as  its  course  would  always  be  disturbed.  We  shall  here  and 
there  remark  on  the  relative  frequency  of  primary  localization  of  tu- 
mors in  the  internal  organs,  but  cannot  go  into  the  symptomatology 
and  histology  of  the  diseased  organ.  On  these  points  you  will  be 
instructed  by  the  pathological  anatomists  and  in  the  medical  clinic. 

[It  has  already  been  mentioned  (page  606)  that  portions  of  foreign 
tissue  may  heal  in  the  body  of  a  living  animal  and  be  nourished 
there  ;  and  even  more  important  for  our  knowledge  about  tumors  is 
the  fact  that  a  tissue  thus  grafted  may  retain  to  some  extent  its  pecu- 
liar physiological  development  :  it  is  possible  to  introduce  small 
fragments  of  periosteum  from  young  animals  into  the  lungs  of  living 
animals,  where  they  may  produce  true  bone  ;  the  same  thing  occurs 
when  the  transplantation  is  into  the  subcutaneous  tissue.  The  peri- 
osteal fragments  do  not  develop  into  a  tumor,  and  the  newly-formed 
bony  plate  is  finally  reabsorbed,  but  the  experiment  shows  that  the 
tissue-cells,  which  render  the  periosteum  a  bone-forming  substance, 
may  preserve  their  vitality  independently  and  for  a  long  time,  even 
when  nourished  from  strange  vessels. 

Besides  spreading  of  tumors  by  cellular  elements,  it  has  been 
supposed  that  they  are  also  conveyed  by  a  contagion  not  connected 
with  cells,  but  by  the  fluids  of  the  neoplasm,  which  are  said  to  have 
a  purely  chemical  influence.  It  must  be  acknowledged  that  some 
cases  placed  in  this  class  are  difficult  to  exjDlain  in  any  other  way. 
Thus  malignant  tumors  with  metastases  to  internal  organs  have 
been  observed  in  pregnant  women,  while  the  foetus  presented  a  neo- 
plasia of  similar  structure.  Since  at  present  it  is  generally  supposed 
that  solid  elements  do  not  pass  from  the  maternal  organs  to  the  fetal 
placenta,  these  observations  must  await  an  exhaustive  explanation. 

Various  observers  have  suggested,  as  causes  for  certain  tumors, 
disturbances  in  the  original  germ-layers  of  the  embryo,  and  lately 
Cohnheim  has  proposed  a  theory  of  the  same  kind.  But  it  is  not 
yet  explained  what  this  defect  is  :  he  thinks  it  simplest  to  suppose 
that  in  an  early  stage  of  embryonal  development  more  cells  are  pro- 
duced than  are  required, so  that  some  remain  unused  ;  these  maybe 
small  in  amount,  but  from  their  embryonal  nature  have  a  great 
faculty  for  increasing.  The  time  of  this  production  of  superfluous 
cells  would  be  in  a  very  early  period — according  to  Cohnheim,  be- 


CAUSES  OF  TUMORS.  683 

tween  the  complete  differentiation  of  the  germ-layers  and  the  for- 
mation of  special  organs.  It  may  further  be  supposed  that  the 
cell-material  is  either  regularly  spread  over  one  of  the  histogenetic 
germ-layers,  or  remains  at  one  point.  *'  The  latter  would  involve 
subsequently,  local  disposition  to  formation  of  a  tumor ;  the 
former  the  beginning  of  a  system,  as  of  the  skeleton  or  the  skin." 
Cohnheim^s  hypothesis  may  explain  many  points  in  the  develop- 
ment of  tumors  ;  he  rejects  entirely  the  etiological  influence  of  ex- 
ternal irritation,  and  recognizes  error  in  embryonal  disposition  as 
the  sole  cause  of  neoplasia.  This  seems  to  me  to  be  going  too  far ; 
I  think  there  is  no  doubt  that  local  irritations  may  induce  tumors, 
although  the  attempt  to  induce  tumors  in  animals  by  injuries  has 
not  yet  succeeded  ;  but  this  proves  just  as  little  as  the  negative  re- 
sults of  inoculating  tumors.  Moreover,  we  represent  traumatic 
irritations  too  coarsely  ;  they  certainly  had  existed  in  cases  where, 
as  has  often  happened,  tumors  form  at  places  long  irritated  by  a 
fontanel  or  a  wart,  etc.  To  illustrate  from  another  class,  shall  we 
not  refer  ulcers  of  the  leg  to  local  irritation,  because  we  cannot 
induce  them  in  animals  by  irritating  their  legs  ? 

The  question  now  arises.  How  does  infection  occur,  and  what 
are  the  means  of  locomotion  of  the  specific  elements  of  the  tumors  ? 
The  first  means  to  look  at  are  the  blood  and  lymph  vessels.  For 
instance,  if  a  tumor  has  opened  a  large  vein,  so  that  it  can  project 
into  it,  if  the  circulation  be  continued  in  the  vein,  particles  of  the 
tumor  may  be  washed  off  and  carried  to  various  organs  as  emboli  ; 
but  this  is  relatively  rare  ;  extension  occurs  much  more  frequently 
by  means  of  the  lymphatics.  There  is  probably  no  direct  passage 
of  the  cellular  elements  ;  at  least,  this  has  not  been  demonstrated. 
But  it  seems  as  if  the  walls  of  the  vessels  became  diseased,  while  the 
caliber  was  obstructed  by  the  tumor,  and  there  was  a  direct  propa- 
gation of  the  degeneration  to  the  next  lymphatic  glands.  That  this 
mode  is  at  least  frequent  is  shown  by  microscopic  examination  of 
the  coi-ds,  often  perceptible  on  palpation,  which  unite  the  primary 
tumors  with  neighboring  glands  ;  it  has  not  yet  been  shown  how 
the  tumor  elements  pass  from  the  gland  into  the  blood.  Like  the 
lymphatics,  the  blood-vessels  also  often  show  a  progress  of  the  dis- 
ease, and  this  probably  is  the  explanation  of  the  occurrence  of  mul- 
tiple disseminated  tumors  about  the  primary  one.  Quite  lately 
Axel  Key  has  stated  that  investigations  by  himself  and  Eetzius 
show  that  the  whole  nervous  system,  peripheral  as  well  as  central, 
is  provided  with  special  serous  channels  communicating  with  each 
other,  which  may  carry  morbid  germs  in  any  direction.  7i>y  thinks 
that  cells  may  be  transported  by  these  channels,  and  that  this  may 


684  TUMORS. 

account  for  the  multiplicity  of  some  tumors  and  the  metastasis  of 
others.  This  view  is  not  yet  sufficiently  investigated,  but  seems  not 
improbable.] 


LECTURE    XLYI. 

1.  Fibromata :  a,  Soft  ;  6,  Hard  Fibroma.  Mode  of  Occurrence ;  Operations ;  Ligature ; 
Ecrasement ;  Galvano-caustic. — 2.  Lipomata :  Anatomy ;  Occurrence  ;  Course. — 
3.   Chondromata :  Occurrence;  Operation. — 4.   Osteomata:  Forms;  Operation. 

1.    FIBEOMA— FIBEOUS  TUMOR— CONNECTIVE-TISSUE  TUMOE. 

Tumors  composed  chiefly  of  developed  connective  tissue  are 
called  fibromata.  They  occur  in  the  following  forms  :  a.  Soft 
fibrous  or  connective-tissue  tumors.  These  are  quite  frequent,  and 
are  located  almost  exclusively  in  the  cutis  ;  they  are  composed  of 
a  very  tough,  somewhat  cedematous,  white  tissue,  and  are  usually 
covered  by  the  thin  papillary  layer  of  the  cutis.  Microscopic  ex- 
amination shows  loose  connective  tissue,  as  in  the  cutis.  On  the 
surface  of  the  tumor  there  are  almost  always  pointed  papillae,  even 
when  the  tumor  is  developed  in  a  part  of  the  skin  which  normally 
has  no  papillae  ;  in  the  rete  Malpighii  of  these  formations,  there  is 
often  a  brownish  pigment,  which  rarely  extends  deeper  in  the  tissue  ; 
they  may  also  have  large  vessels  and  abnormal  enlargements  of  the 
hair  and  sweat  glands  on  their  surface  ;  they  are  usually  loosely 
hanging  (cutis  pendula,  molluscum  fibrosum),  often  distinctly  pedun- 
culated tumors  ;  they  might  be  termed  partial  hyperplasias  of  the 
skin,  as  they  consist  essentially  of  the  elements  of  the  skin.  The 
growth  is  very  slow,  free  from  pain,  and  often  goes  on  to  the  de- 
velopment of  enormous  tumors.  Occasionally  such  growths  are 
congenital ;  they  may  be  multiple  ;  hundreds  of  them  may  occur  on 
the  surface  of  the  body.  The  congenital  cutis-proliferation  is  most 
frequent  on  the  face,  generally  unilateral,  diffuse  or  in  the  shape 
of  soft,  cock's-comb-like  vegetations.  Freckles,  pigmented  hairy 
mother's-marks  (moles,  benignant  melanoses,  melanoma,  pigmented 
iibroma)  belong  to  this  class.  These  tumors  are  apt  to  occur  toward 
the  end  of  middle  life  ;  in  women,  we  not  unfrequently  find  them 
hanging  from  the  labia  majora  ;  as  growths  on  this  part  are  concealed 
as  long  as  possible,  they  are  usually  quite  large  when  first  seen  by  the 
surgeon,  Virchoio  terras  the  disease,  in  which  these  multiple,  soft, 
fibrous  tumors  develop,  leontiasis ;  in  the  course  of  time  they  are 
occasionally  accompanied  by  general  disturbances  of  nutrition.  Al- 
though these  tumors  are  not  infectious,  in  the  meaning  we  have  at- 
tributed to  this  word,  they  occasionally  lead  to  a  cachectic  state,  and 


« 


FIBROMATA. 


685 


Fia  115. 


in  the  course  of  years  to  death  by  marasmus.  There  is  also  a  relation- 
ship between  this  disease  and  Oriental  elephantiasis,  although  by  this 
name  we  mean  a  more  nodular,  but  at  the  same  time  rather  diffuse 
hypertrophy  of  the  cutis  of  certain  parts  of  the  body  (labia  pudenda, 
Bcrotum,  legs),  which  runs  its  course  with  repeated  erysipelas.  Tliere 
would  be  less  misunderstanding  if  these  developments  were  briefly 
termed  hypertrophy  of  the  skin  or  pachydermata.  Elephantiasis 
Grsecorum  is  a  similar  disease  as  far  as  regards  the  cutaneous  tliick- 
ening,  but  it  is  strongly  endemic,  and  is  accompanied  by  some  ner- 
vous symptoms ;  it  occurs  in  Greece,  Asia,  and  Norway  (under  the 
name  of  Spedalsked),  and,  after  inducing  long  suffering,  usually  proves 
fataL 

h.  Firm  fibromata^  fibroid^  des- 
moid tumors  appear  to  the  naked 
eye  to  be  composed  of  very  firm, 
closely  -  interlaced  fibrous  tissue. 
They  are  always  very  hard,  and  of 
roundish  or  tuberous  form;  their 
cut  surface  is  pure  white,  or  pale 
reddish ;  to  the  naked  eye  many 
of  them  show  on  their  cut  surface 
a  very  peculiar,  regular  layering, 
and  a  concentric  arrangement  of 
filaments  around  distinct  axes  (see 
Fig.  115)  ;  according  to  my  investi- 
gations, this  results  from  the  fibrous 
formation     taking    place     around 

nerves  and  vessels,  the  latter  being  consequently  embedded  in  the 
midst  of  the  fibrous  layers  ;  frequently  the  nerves  are  thus  destroyed. 

With  the  external  peculiarities  just  described,  the  histological  ap- 
pearance renders  it  difficult  to  classify  these  tumors.  There  can  be  no 
doubt  that  those  of  them  which  consist  chiefly  of  connective  tissue, 
Buoh  as  old  uterine  fibroids,  should  be  called  fibromata;  but  the 
younger  tumors  of  this  variety,  with  the  same  appearance  and  con- 
sistence, show  little  connective-tissue  but  numerous  spindle-shaped 
cells.  The  significance  of  these  cells  is  varied.  Virchoio  considers 
them  muscle-cells  ;  hence,  what  have  hitherto  been  called  fibroids 
of  the  uterus,  he  does  not  class  among  the  fibromata,  but  among 
rayomata,  and  terms  them  "myoma  lyevicellulare."  If  we  consider 
fibre-cells  as  young  connective-tissue,  we  must  christen  these  tumors 
spindle-celled  sarcoma  or  fibro-sarcoma.  You  see  here,  in  apparently 
simple  fibrous  tissues,  we  become  involved  in  difficulties  wath  his- 
tology and  histogeny. 


Small  fibroma  (myo-flbroma)  of  the  nteras : 
natural  size  of  the  section. 


686 


TUMORS. 


[One  reason  for  distinguisliing  this  tumor  from  sarcomata  is  that 
in  the  uterus  rapidly-growing  recurrent  tumors  develop,  in  whose 
older  parts  the  structure  of  fibroma  predominates,  while  the  younger 
portions  contain  quantities  of  spindle-cells — true  sarcoma-cells. 
Clinically  these  tumors  do  not  act  like  the  much  more  frequent 
myomata,  but  like  sarcomata.  Some  pathologists  assume  that  in 
these  cases  there  has  been  a  development  of  a  sarcoma  in  a  fibroma  ; 
but  it  is  more  natural,  from  the  predominance  of  the  signs,  to  class 
these  tumors  as  sarcomatous.] 

There  are  two  things  that  would  induce  me  to  regard  fibro-cel- 
lular  tumors  as  myomata  :  i.  e.,  the  oval  and  finally  rod-like,  wavy 
form  of  the  nuclei,  and  the  very  distinct  arrangement  of  the  fibrous 
layers  into  bundles,  while  the  individual  fibre-cells  are  isolated  with 
difficulty,  perhaps  only  by  aid  of  the  recognized  chemical  means. 
At  the  same  time  the  soil  in  which  the  tumor  is  developed  is  very 
important ;  the  probabilities  for  a  myoma  would  be  very  great  if 
the  neoplasia  occur  in  the  substance  of  the  uterus. 

Fig.  116. 


Prom  a  myo-flbroma  of  the  nteras.  Macrnified  350  diameters.   Oblique  ami  loDgitudinal  section 
of  muscular  cell-biindlee. 

FibroEftata  are  capable  of  some  anatomical  metamorphoses.  Par- 
tial mucous  softening,  great  serous  infiltration  (brawny  appearance 
and  consistence),  calcification,  and  even  true  ossification,  are  not  very 
rare.    Superficial  ulceration  is  quite  frequent  in  fibromata  lying  close 


FIBROMATA. 


687 


under  a  mucous  membrane ;  it  results  from  external  injuries  in  tlie 
usual  way.  The  ulcer,  thus  formed,  often  shows  good  granulations 
and  suppuration,  and,  under  favorable  circumstances,  it  may  be  brought 
to  cicatrize.  Fibrous  tissue,  though  apparently  poor  in  vessels,  often 
contains  quite  a  number,  both  of  arteries  and  veins,  as  may  be  shown 
by  injections  ;  occasionally  a  very  coarse  cavernous  net-work  of  veins 
forms  in  it  (see  Fig.  117) ;  arteries  and  veins  are  so  intimately  united 
with  the  tissue  of  the  tumor,  that  their  adventitia  mostly  disappears 
in  it,  so  that,  in  case  they  are  injured,  they  cannot  retract  either  trans- 
versely or  longitudinally,  and  they  remain  gaping.     This  is  the  ana- 


Fig.  UT 
b 


a  and  6,  vessel?  of  acntis  fibroma  (myoma  ?)  from  the  thigh,  injected  through  an  artery  ;  b,  cav- 
ernous veins:  c,  peculiar  regularly-arranged  veins  of  a  cutis  fibroma  (myo-flbroma  ?)  of 
the  abdonilnal  walls,  injected  through  a  vein.    Magnified  GO  diameters. 


toinical  mechanical  cause  for  bleeding  from  fibromata  being  so  pro- 
fuse, and  why  frequently  it  is  not  arrested  without  artificial  aid.  The 
rigid  gaping  opening  of  the  vessel  renders  the  formation  of  a  thrombus 
very  difficult.  Occasionally,  in  large  uterine  and  in  periosteal  fibro- 
mata, we  find  lacunar  fissures  filled  with  thin  serum;  possibly  these 
are  ectatic  pathological  newly-formed  lympli  sinuses ;  there  are  no 
certain  observations  on  this  point.  Cavities,  as  large  as  the  head, 
filled  with  serum,  also  occur  in  uterine  fibromata  (Spencer  Wells). 

The  localization  of  fibroma  varies  greatly ;  of  all  the  organs  the 
uterus  is  most  frequently  affected  (if  under  the  general  term  "  fibroid  " 
we  include  myo-fibroma) ;  here  these  tumors  occasionaliv  attain  an 


688  TUMORS. 

enormous  size,  and  then  not  unfrequently  calcify.  Tliej  are  usual];9 
roundish,  and  are  distinctly  and  sharply  bounded :  they  are  most  fre- 
quent in  the  body  of  the  organ,  rarer  in  the  neck,  and  hardly  ever 
occur  in  the  vaginal  portion ;  their  growth  progresses  upward  and 
downward,  that  is,  into  the  abdomen,  gradually  stretching  the  perito* 
noeum,  or  through  the  os  uteri  into  the  vagina.  In  the  latter  direction 
the  tumors  continue  to  grow,  become  pedunculated,  and  often  give 
rise  to  severe  hiemorrhages  ;  they  are  called  Jibrous  uteri7ie  polypi. 

Fibromata,  starting  from  the  periosteum,  are  quite  frequent ;  they 
are  almost  always  fibro-sarcomata,  i.  e.,  they  are  composed  of  fibres 
and  spindle-shaped  cells,  the  latter  may  even  preponderate  (fibrous 
sarcoma,  HokitansJcy).  The  periosteum  of  the  bones  of  the  skull  and 
face  is  particularly  liable  to  this  disease,  especially  the  inferior  turbi- 
nated bone  ;  from  this  pohit  fibromata  project  into  the  nasal  cavities 
and  fauces  as  ^Dolypous  growths  (fibrous  naso-pharyngeal  polypi) ; 
by  pressure  they  may  cause  reabsorption  of  the  bone  and  grow  into 
the  cranium  or  antrum  Highmori ;  they  are  particularly  vascular.  J 
have  also  seen  fibromata  on  the  periosteum  of  the  tibia  and  clavicle,  and 
in  bone  itself,  as  in  the  upper  maxilla,  where  I  have  met  strange  com- 
binations of  chondroma  and  fibroma.  Lastly,  we  have  to  mention  that 
fibromata  are  not  rare  in  and  on  the  nerves  (Fig.  118).  Frequently  all 
tumors  occurring  on  nerves  are  called  neuromata^  but  they  are  distin- 
guished according  to  their  anatomical  cliaracteristics ;  most  neuromata 


Fia.  na 


Fio.  119. 


Neuroma,  after  Fillin 


SmRlI  nodular  flbro-parcomatouc  neu- 
romata from  the  eyelid  of  a  boy ; 
natural  eize. 


ire  fibromata  or  fibro-sarcomata  in  the  nerve-trunks;  others  consist 
partly  or  entirely  of  newly-formed  nerve-filaments  {true  nexiromatd, 


FIBROMATA.  689 

Sometimes  the  nerve-fibromata  follow  the  nerve-trunks  and  form  nod- 
ular cords  (plexiform  neuromata,  Verneuil)  (Fig.  118),  on  whose  con- 
fluence, as  already  stated,  the  peculiar  appearance  of  the  cut  siu-face 
of  the  fibroma  (Fig.  115)  occasionally  depends.  Fibroma  is  rare  in 
the  subcutaneous  cellular  tissue ;  in  the  glands,  except,  perhaps,  in  the 
mamma,  it  hardly  ever  occurs. 

The  fibrous  tumors  just  enumerated  are  particularly  apt  to  develop 
in  middle  age  (from  thirty  to  fifty  years)  ;  they  are  rarer  in  youth,  and 
still  more  rare  in  advanced  age.  \Vlien  we  find  them  in  the  uterus 
of  old  women,  there  will  probably  have  been  there  many  years.  Only 
fibroid  neuromata,  and  bone  and  periosteal  fibromata,  occur  in  young 
persons,  not  exactly  in  children  (though  I  saw  one  case  of  neuro-fibroma 
in  a  boy  seven  years  old),  but  usually  after  puberty.  Fibromata 
are  somewhat  more  frequent  in  women  than  in  men ;  uterine  fibromata 
develop  about  the  thirty-fifth  to  the  forty-fifth  year,  although  the 
trouble  from  them  is  often  experienced  later ;  they  are  rather  more 
frequent  multiple  than  solitary ;  periosteal  fibromata  usually  remain 
sohtary,  but  not  unfrequently  return,  though,  perhaps,  not  for  years 
(regional  recurrence ;  relation  to  sarcoma).  Usually  the  growth  of 
fibroma  is  purely  central,  and  they  are  not  infectious  ;  but  infectious 
fibromata  are  said  to  occur.  Several  such  tumors  near  together  unite, 
infiltrate  the  surrounding  parts,  and  occasionally  cause  fibroid  degen- 
eration of  the  neighboring  muscles,  bones,  and  lymphatic  glands.  The 
infectious  fibromata  that  I  have  seen  were  always  fibro-sarcomata ; 
like  pure  sarcomata,  they  may  appear  as  metastases  in  the  lungs. 
Fibromatous  neuromata  are  quite  frequently  multiple,  especially  in 
difi'erent  branches  of  the  same  nerve.  Some  time  since  I  extirpated 
six  neuromata  from  one  man  ;  three  from  the  left  arm,  three  from  the 
left  lower  extremity.  Cases  have  been  seen  where  there  were  twenty 
or  thirty  neuromata  at  once. 

Pure  fibromata  usually  groAV  very  slowly,  and  in  age  their  growth 
is  occasionally  checked.  This  is  best  known  of  fibroma  of  the  uterus, 
which  usually  ceases  to  grow  after  the  change  of  life,  and  then  often 
becomes  calcareous.  Combinations  with  other  tissue-formations,  es- 
pecially with  sarcoma,  as  already  stated,  occur,  and  take  place  in  such 
a  way  that  the  primary  tumors  present  a  fibrous  consistence,  while  the 
recurring  tumors  and  secondary  tumors  resulting  from  infection  are 
soft  cellular  sarcomata.  I  have  seen  such  cases.  A  man  about  twen- 
ty-five years  old,  of  healthy  appearance,  had  a  fibro-sarcoma  as  large 
as  a  walnut,  in  the  abdominal  walls ;  it  was  entirely  removed  ;  a  new 
tumor  appeared  in  the  wound ;  subsequently  several  soft  tumors  ap- 
peared at  other  points  on  the  surface  of  the  bodj'' ;  at  the  same  time 
the  patient  became  marasmic  and  died  in  a  few  months ;  the  whole 

lung  was  filled  with  soft  sarcomatous  tumors, 
•io 


690  TUMORS. 

[Fibromata  of  the  abdominal  walls,  which  usually  start  from  the 
sheath  of  the  recti  muscles  or  the  aponeuroses  of  the  oblique  muscles 
and  passing  inward  unite  with  the  peritonaeum,  grow  rapidly  and  in 
this  respect  resemble  sarcoma.  Lately  I  saw  a  woman,  thirty-nine 
vears  old,  who  for  years  had  a  uterine  fibroid  as  large  as  a  child's 
head,  in  whom  was  developed  a  fibroma,  the  size  of  a  plum,  in  the 
abdominal  walls,  which  was  painful  spontaneously  as  well  as  on 
pressure.     Possibly  this  was  a  neurofibroma. 

Large,  deeply-seated  fibromata,  with  broad  bases  not  accessible 
for  operation,  are  met  with.  Surgery  has  made  great  advances  in 
such  cases  of  late  years  ;  and  immense  fibromata  have  been  removed 
alone  or  with  the  uterus  by  abdominal  section.  Fibroids  of  smaller 
size,  pi-ojecting  into  the  uterus,  after  dilatation  of  the  os  uteri  are 
ermcleated  and  removed  through  the  vagina.  A  reason  for  this 
operation  not  being  done  more  frequently  than  it  has  been,  is  the 
slight  amount  of  annoyance  usually  caused  by  such  tumors  ;  and 
the  fact  that  in  time  they  cease  to  grow,  so  that  often  it  is  unjus- 
tifiable to  submit  the  patient  to  any  dangerous  operation.  Of  late, 
too,  in  large  uterine  fibroids  subcutaneous  injections  of  ergotine 
have  proved  successful.  Under  this  treatment  the  tuiuors  shrink 
away,  or  at  least  the  ha3morrhages  cease.] 

After  what  has  been  said,  the  diagnosis  of  fibroma  is  not  difBcult , 
the  consistence,  locality,  age,  mode  of  attachment,  and  form  of  the 
tumor,  almost  always  lead  to  its  correct  recognition. 

The  treatment  consists  exclusively  in  the  removal  of  the  tumor. 
When  practicable,  this  is  generally  done  with  the  knife  ;  but  pedun- 
culated or  hanging  connective-tissue  tumors  and  fibrous  polypi  admit 
of  other  methods  of  operation.  Formerly  the  ligature  was  much  re- 
sorted to  in  such  cases,  i.  e.,  the  pedicle  of  the  tumor  was  tied  tightly 
with  a  thread,  so  that  it  became  gangrenous  and  fell  ofi";  this  method 
was  chosen  especially  in  cases  where  bleeding  from  the  cut  surface 
was  feared.  Ligation  has  the  great  disadvantage  that  then  the  tumor 
decomposes  in  or  on  the  body,  and  that  the  ligature  must  be  tightened 
several  times  before  it  cuts  through  ;  this  may  induce  severe  hasmor- 
rhage.  The  ligature  may  be  combined  with  incision,  by  cutting  off 
the  tumor  in  front  of  the  ligatiu-e,  and  leaving  only  part  of  the  pedicle 
to  become  detached  spontaneously.  In  the  nares  and  pharynx,  as 
well  as  in  the  vagina,  there  is  of  course  great  dilEculty  in  applying  a 
ligature,  and  for  this  purjDOse  numerous  instruments,  simple  and  com- 
plicated, so-called  loop-bearers,  have  been  constructed,  by  means  of 
which  the  ligature  is  passed  over  the  tumor  on  to  the  pedicle.  But 
the  ligature  is  now  so  generally  rejected  and  so  little  used,  that  all 
these  instruments,  some  of  which  are  very  ingenious,  are  for  the  mosi 
part  only  of  historical  value. 


FIBROMATA— OPERATIONS.  6  9 1 

[Simple  ligation  of  tumors  is  rarely  done  now  ;  in  its  place  is  used 
the  elastic  ligature,  which  is  more  energetic  and  certain.  For  this 
purpose  simple  rubber  drainage-tubes  of  various  caliber,  or  solid 
rubber  ligatures,  are  employed.  The  whole  pedicle  may  be  ligated 
at  once  or  in  portions,  by  thrusting  a  trocar  through  the  base  of 
the  pedicle  and  passing  ligatures  through  the  canula,  and  ligating 
different  portions.  The  elastic  ligature  should  be  drawn  as  tight 
as  jDOSsible,  so  as  to  cut  off  the  circulation  ;  to  prevent  the  ligature 
from  slipping,  two  needles  may  be  thrust  through  at  right  angles  be- 
tween the  ligature  and  tumor.  When  the  ligation  has  been  done,  the 
ligatures  cut  through  quite  soon  ;  but  this  is  not  generally  waited 
for,  the  tumor  being  often  removed  by  the  thermocautery  ;  in  doing 
this  it  is  well  to  keep  below  the  needles,  so  the  ligature  may  hold  well.] 

But  the  desire  to  remove  pedunculated  tumors  without  haaraor- 
rhage  is  still  strong,  and  has  lately  led  to  new  instruments  and  new 
methods,  which,  however,  could  not  have  become  popular  before  the 
introduction  of  chloroform.  Crushing  and  hurnhig  off  have  now 
taken  the  place  of  the  ligature,  ^crasement  as  done  by  Chassaignac 
we  have  already  described  ;  this  operation,  if  done  slowly,  is  fol- 
lowed by  no  haemorrhage,  even  from  arteries  of  the  diameter  of  the 
radial  ;  the  resulting  wound  is  perfectly  smooth  and  regular,  and 
heals  well  without  much  sloughing f from  the  surface;  although 
hemorrhage  is  not  certainly  avoided  in  all  cases,  it  is  in  most ;  the 
instrument  is  made  of  various  sizes  ;  the  smallest  may  be  passed 
into  the  nose,  and  with  it  we  may  readily  crush  off  small  peduncu- 
lated naso-pharyngeal  polypi.  The  galvano-caustic  of  MAMledorpf 
is  a  method  of  similar  effect ;  its  object  is  to  heat  a  loop  of  platinum 
wire  between  the  two  poles  of  a  galvanic  battery,  and  with  it  burn 
through  the  base  of  the  tumor  ;  the  result  is  a  simultaneous  division 
and  arrest  of  haemorrhage  ;  the  latter  fails  about  as  often  as  it  does 
in  ecrasement,  that  is,  very  rarely— hence  this  method  is  advisable 
in  certain  cases.  The  trouble  in  preparing  a  strong,  active  battery 
(which  is  quite  expensive)  is  such  that  galvano-caustic  will  probably 
never  come  into  general  use  ;  in  spite  of  its  elegance,  it  has  been 
strangled  almost  at  its  birth  by  the  introduction  of  the  ecraseur ; 
the  medical  public  has  already  decided  the  question  ;  almost  every 
operating  surgeon  has  an  ecraseur,  only  a  few  hospitals  have  gal- 
vano-caustic apparatuses. 

As  regards  operation  for  non-pedunculated,  more  deeply-seated 
fibromata,  some  of  them  are  not  at  all  accessible  to  surgical  treat- 
ment ;  we  cannot  recommend  cutting  uterine  fibromata  out  of  the 
abdomen,  not  because  the  operation  is  excessively  dangerous,  but 
because,  in  the  course  of  time,  these  tumors  usually  come  to  a  stand- 


092  FIBROMATA,  LIPOMATA. 

still,  and  the  annoyance  they  cause  rarely  balances  the  danger  to  life. 
As  regards  those  fibromata,  also,  which  are  not  dangerous  from  their 
seat  or  growth,  but  to  operate  on  which  would  be  dangerous,  we 
should  bear  in  mind  that  these  tumors  grow  very  slowly,  often  come 
to  a  halt  in  advanced  life :  hence  we  should  not  undertake  such  opera- 
tions too  hastily,  or  urge  them  too  strongly.  But  there  are  many 
cases  where  we  may  and  must  operate  without  hesitation ;  extensive, 
frequently-repeated  haemorrhages  from  an  ulcerated  fibroma,  threat- 
ened destruction  of  bone,  or  protrusion  into  the  skull,  are  urgent 
indications.  In  neuro-fibromata  the  pain  is  sometimes  so  severe  that 
the  patients  strongly  urge  operation,  even  if  we  have  to  tell  them 
that  paralysis  of  the  parts  supplied  by  the  nerve  affected  would  be 
the  necessary  result,  for  we  almost  always  have  to  excise  a  portion 
of  the  diseased  nerve  which  possibly  still  performs  part  of  its  func- 
tions.    If  the  neuroma  be  painless,  it  would  be  foolish  to  excise  it. 

a.  LIPOMATA— FATTY  TUMOES. 

Of  course,  the  disposition  to  formation  of  fat,  wlien  it  does  not 
exceed  a  certain  point,  is  not  regarded  as  a  morbid  diathesis,  but 
rather  as  a  sign  of  good  nutritive  condition,  and  varies  Math  the  age, 
being  greatest  between  the  thirtieth  and  fiftieth  year,  and  being  es- 
sentially favored  by  a  quiet,  pleasant  life  and  phlegmatic  disposition. 
We  only  begin  to  regard  it  as  a  disease  when  it  induces  functional 
disturbance  of  different  organs,  or  of  the  organism  at  large,  or  if  the 
development  of  fat  be  limited  to  a  small  part  of  the  body,  when  it 
appears  as  a  fatty  tumor. 

[Fatty  tumors,  or  lipomata,  are  analogous  to  the  normal  type  of 
fatty  tissue  in  the  embryo :  Toldt  has  found  that  in  the  embryo 
the  fatty  tissue,  which  subsequently  is  diffused,  develops  at  certain 
parts  of  the  body  as  distinct  lobular  masses,  characterized  by  a  sup- 
ply of  blood  independent  of  the  neighboring  tissues.  The  peculiar 
cells,  which  Toldt  considers  distinct  from  connective  tissue,  during 
intrauterine  life  contain  usually  no  large  drops  of  fat ;  hence  to  the 
naked  eye  they  closely  resemble  gland-tissue.] 

The  anatomical  formation  of  fatty  tumors  is  simple  ;  they  consist 
of  fatty  tissue,  which,  like  the  subcutaneous  fat,  is  divided  into  lobes 
by  connective  tissue.  This  connective  tissue  may  be  more  or  less  de- 
veloped, and  the  tumor  may  consequently  be  sometimes  firm  (fibro- 
matous  lipoma),  sometimes  softer  (simple  lipoma).  The  shape  is 
usually  round  and  lobular,  and  the  fatty  mass  separated  from  the  ad- 
jacent structures  by  a  thickened  layer  of  connective  tissue  (circum- 
scribed lipoma,  the  usual  form),  and  may  readily  be  separated  from 
the  parts  around  ;  more  rarely,  lipoma  appears  as  a  corpulence  limited 


TUMORS.  693 

to  one  part  of  the  body,  as  a  swelling  without  distinct  boundaries 
(diffuse  lipoma).  The  seat  of  lipoma  is  most  frequently  in  the  subcu- 
taneous cellular  tissue,  especially  of  the  trunk ;  these  tumors  are  most 
frequent  on  the  back  and  abdominal  walls;  they  are  rarer  on  the  ex- 
tremities ;  in  the  synovial  folds  and  tufts  of  the  joints,  as  well  as  in 
the  sheaths  of  the  tendons,  there  may  be  an  abnormal  development 
of  fat,  so  that  the  fatty  masses  may  seem  branched  like  a  tree  (lipo- 
ma arborescens,  J.  3Iuller) ;  this  is  an  analogy  to  the  fatty  prolifera- 
tion in  the  processes  of  the  peritonreum  of  the  colon  (appendices 
epiploicre)  and  other  serous  membranes,  but  it  is  exceedingly  rare. 
The  growth  of  lipoma  is  always  very  slow,  its  development  is  hardly 
ever  accompanied  by  pain,  unless  it  comes  close  to  a  nerve  and  presses 
on  it,  which  rarely  happens.  Fatty  tumors  may  attain  a  great  size ; 
the  patients,  being  little  troubled  by  them,  rarely  feel  obliged  to  have 
them  removed  early.  Hence  lipomata  grow  to  enormous  tumors  ; 
recently  I  removed  one  from  the  back  of  a  M^oman  ;  it  began  under 
the  right  scapula  and  reached  down  to  the  calves  ;  above,  at  its  base, 
it  was  the  same  circumference  as  the  larger  part  of  the  patient's  thigh, 
below  it  was  almost  twice  as  large.  Secondary  changes  in  these  tu- 
mors are  not  very  frequent,  but  the  thick  connective-tissue  partitions 
in  the  tumor  may  calcify,  or  even  ossify,  and  at  the  same  time  the  fatty 
tissue  may  change  to  an  oily  or  emulsion-like  fluid.  The  skin  covering 
the  tumor  is  gradually  expanded,  and  at  first  is  usually  much  thickened, 
and  occasionally  colored  brown,  but  generally  remains  movable  over  the 
tumor ;  excej^tionally  there  is  an  intimate  adhesion  with  the  newly- 
formed  fat,  and  then  a  superficial  ulceration  of  the  cutis,  which  in  such 
cases  is  entirely  atrophied  ;  this  ulceration,  which  may  be  induced  by 
external  irritation,  rarely  goes  deep,  although  parts  of  the  fatty  tissue 
may  become  gangrenous ;  under  such  circumstances  there  are  almost 
always  formed  ulcers  with  slightly-developed  granvilations  and  serous, 
badly-smelling  secretions.  Combinations  of  liiDomawith  soft  fibroma, 
with  myxomatous  sarcoma,  and  with  lymphoma,  do  occur,  although 
rarely.  In  lipoma  I  have  several  times  seen  considerable  cavernous 
dilatation  of  the  veins. 

A  disposition  to  the  development  of  lipoma  most  frequently  exists 
at  the  time  of  life  when  the  tendency  to  development  of  fat  generally 
is  greatest,  between  the  thirtieth  and  fiftieth  years ;  in  children  it  is 
very  rare,  still  it  occurs  congenitally  on  the  back,  neck,  face,  as  well  as 
on  the  toes,  with  coincident  hypertrophy  of  the  bones  (giant  growth) ; 
they  grow  little  after  birth.  Usually  there  is  only  one  lipoma,  and  it 
grows  very  slowly ;  indeed,  it  may  remain  at  one  point,  especially  in 
old  persons.  In  the  subcutaneous  cellular  tissue,  development  of 
multiple  lipoma  has  been  frequently  seen;    cases  have  been  noted 


694  LIPOMATA,  CHOXDROMATA. 

tv^here  fifty  or  more,  usually  small  lipomata,  were  developed  at  once; 
subsequently  they  ceased  to  grow.  Multiple  lipomata  are  often  mixed 
tumors.  Simple  lipoma  is  never  infectious ;  hence  it  never  recurs  after 
extirpation. 

Pressure  and  friction  are  occasionally  observed  as  exciting  causes 
for  the  development  of  fatty  tumors ;  there  is  also  a  moderate  degree 
of  hereditary  influence  in  fatty  disease  generally. 

The  diagnosis  of  lipoma  is  generally  easy;  the  consistence,  the 
lobular  feel,  occasionally  a  perceptible  crackling,  from  compression  of 
individual  fat-lobules,  are  the  objective  symptoms;  other  aids  for  con- 
firming the  diag-nosis  are,  the  movability  of  the  tumor,  the  slow 
growth,  age  of  the  patient,  and,  above  all,  the  region  of  the  body; 
there  is  a  possibility  of  mistaking  them  for  fibrous  tumors,  sarcomata, 
lipomatous-cavernous  blood-tumors. 

The  treatment  consists  in  removal  with  the  knife.  Healing  is 
usually  preceded  by  free  discharge  of  gangrenous  tissue  from  the 
wound;  in  very  large  lipomata  it  is  best  always  to  remove  a  portion  of 
the  skin  covering  it,  with  the  tumor ;  after  their  extirpation  erysipelas 
is  quite  frequent,  especially  in  very  fat  patients.  The  largest  lipomata 
may  be  removed  with  good  result,  as  they  usually  occur  in  persons 
otherwise  healthy.  Extirpation  of  diifuse  lipomata  is  more  unfavor- 
able than  that  of  the  circumscribed  ;  the  local  and  general  reaction  is 
usually  more  considerable,  but  I  have  several  times  performed  such 
operations  with  good  results. 

3.  CHONDBOMATA— CARTILAGE-TUMOES. 

These  are  tumors  consisting  of  cartilage,  of  the  hyaline  or  fibrous 
variety.  The  microscopic  ele7nents  of  pathological,  newly-developed 
cartilage  may  varv ;  occasionally  we  see  exceedingly  beautiful  round 
cartilage-cells,  such  as  are  particularly  found  in  the  embryo,  and  some- 
what smaller  in  the  articular  and  costal  cartilage;  but  such  a  complete 
change  of  hyaUne  substance  to  a  homogeneous  mass,  as  is  the  rule  in 
normal  cartilage,  is  more  rare  in  chondromata ;  frequently  the  inter- 
cellular substance  pertaining  to  the  different  groups  of  cells  is  distinct, 
and  between  the  large  groups  of  cells  the  hyaline  substance  forms  fine 
filaments.  The  latter  is  the  cause  of  sections  of  cartilage-tumors 
having  the  appearance  of  being  traversed  by  capsular-like,  communi- 
cating connective-tissue  meshes,  which  even  to  the  naked  eye  shoAv  a 
kind  of  net-work ;  the  bluish  or  yellowish  glistening  cartilage  is  seen 
embedded  between  these  connective-tissue  strijE.  The  tissue  of  chon- 
droma also  distinguishes  itself  from  that  of  normal  cartilage  by  the 
fact  that  the  formsr  is  usually  vascular  in  the  above-mentioned 
fibrous  striae,  while,  as  is  well  known,  the  latter  has  no  vessels.     Tlie 


TUMORS. 


695 


microscopic  appearances  in  cliondroma  have  still  some  other  points  of 
difference  from  those  of  normal  cartilage.  Not  unfrequently  the  inter- 
cellular substance,  whether  hyaline  or  slightly  striated,  instead  of 
having  the  regular  firm  consistence  of  normal  cartilage,  is  more  gelat- 
inous or  friable,  or  possibly  becomes  so  secondarily.  Calcification  of 
the  cartilage,  as  well  as  true  ossification,  is  quite  frequent  in  chon- 
droma; the  forms  of  the  cells  may  vary  greatly  (Fig,  120). 

Fig.  120. 


Extraordinary  forms  of  cartilasre-tissne  from  chondromata,  taken  from  men  f.nd  doys. 
'Magnified  360  diameters. 


In  shape,  chondromata  are  usually  roundish,  nodular,  sharply- 
bounded  tumors,  which  may  grow  to  the  size  of  a  man's  head,  or 
larger.  At  first  their  growth  is  almost  purely  central ;  subsequently, 
however,  the  tumor  enlarges,  partly  from  the  occurrence  of  new  foci 


696  CHONDEOMATA. 

of  disease  in  the  immediate  vicinity,  partly  from  transformation  of  the 
adjacent  tissue  into  cartUage  (local  infection).  Among  the  anatomical 
metamorphoses,  the  puljDy  and  mucous  softening,  and  the  ossification 
of  individual  parts,  have  been  already  mentioned ;  the  former  causes 
mucous  cysts  in  these  tumors,  which  give  a  feeling  of  partial  fluctua- 
tion to  the  otherwise  hard  chondroma.  It  is  imaginable  that,  with 
complete  ossification  of  the  chondroma,  the  tumor  would  cease  to 
grow;  and  this  has  been  seen  in  some  cases,  although  rarely.  In  large 
chondromata  superficial  ulceration  is  apt  to  occur,  especially  if  the 
skin  is  very  tense,  or  from  occasional  traumatic  irritation,  but  it  is  of 
no  great  importance.  Ulcerative  central  softening  and  perforation 
outwardly  are  rare,  but  once  I  saw  it  occur  in  a  typical  chondroma, 
the  size  of  a  large  apple,  on  the  sheath  of  one  of  the  tendons  of  th(^ 
foot. 

Virchow  calls  the  ossifying  cell-layer  between  the  periosteum  and 
growing  bone,  osteoid  cartilage ;  hence  he  terms  periosteal  and  ossi- 
fying tumors,  which  have  a  formation  similar  to  this  osteoid  cartilage, 
"  osteoid  chondromata."  I  am  doubtful  about  any  one  being  able  to 
distinguish  such  tumors,  which  I  have  often  examined,  from  periosteal 
ossifying  round-celled  or  spindle-celled  sarcomata;  hence  I  prefer  not 
separating  Vlrchovy's  osteoid  chondroma  from  the  sarcomata. 

Occurrence.  Cartilage-tumors  are  particularly  apt  to  develop  on 
the  bones.  The  phalanges  of  tte  hand  and  the  metacarpal  bones  are 
the  most  frequent  seat  c\f  chondromata;  much  more  rarely  the  analo- 
goiis  bones  of  the  foot.  On  the  hand,  chondromata  are  almost  alwaj's 
multiple ;  they  even  occur  in  such  numbers  that  scarcely  a  finger  re- 
mains free  from  them.  The  bones  next  most  liable  are  the  femur 
and  pelvis ;  here  the  tumors  attain  the  largest  size,  and  lead  to  com- 
plete destruction  of  these  bones.  Chondromata  are  rarer  on  the 
bones  of  the  face  and  skull,  but  somewhat  more  frequent  on  the  ribs 
and  scapula.  They  occasionally,  but  rarely,  develop  in  the  sheaths 
of  the  tendons.  In  the  soft  parts  also,  especially  in  the  glands  (tes- 
ticles, ovaries,  mammae,  salivary  glands,  etc.),  cartilaginous  growths 
have  been  observed,  sometimes  in  the  shape  of  fully-developed  chon- 
droma, sometimes  as  single  pieces  of  cartilage,  with  a  predominance 
of  sarcomatous  or  carcinomatous  growth. 

The  development  of  chondroma  is  chiefly  peculiar  to  youth  ;  not 
that  it  occurs  exactly  in  children,  but  shortly  before  the  age  of  pu- 
berty. Most  chondromata  are  referable  to  this  age,  even  if  they  are 
first  recognized  much  later  in  life.  The  tumors  occasionally  develop 
after  injury,  grow  very  slowly  for  twenty  or  thirty  years,  and  occa- 
sionally seem  to  cease  growing  entirely.  I  have  heard  patients  as- 
sert that  the  tumors  had  remained  unchanged  for  years,  and  some  ac- 


TUMORS. 


697 


cidental  cause  made  iLem  desirous  of  haWng  them  removed.  Some- 
times they  grow  more  rapidly  and  become  infectious;  cases  are 
known  where  cartilaginous  tumors  have  appeared  even  in  the  lungs 
(embolic)  and  caused  death.  0.  Weber  has  also  observed  an  hereditary 
chondroma!  diathesis.  In  the  combinations  of  cartilage-formations 
with  sarcoma  or  carcinoma,  the  former  has  no  eflfect  on  the  prognosis 
of  the  tumor  as  a  whole. 

Fig.  121. 


Chondroma  of  the  fingers. 


The  diagnosis  and  prognosis  may  readily  be  inferred  from  what 
Has  been  said.  We  must  only  add  that  the  softened  and  cystoid 
forms  of  chondroma  often  figure  in  old  works  under  the  names  col- 
loid tumors,  gelatinous  cancer,  alveolar  cancer,  etc.      As  the  epitho 


69 S  CHOXDROMATA,  OSTEOMATA. 

lial  elements  and  connective-tissue  framework  may  become  gelatinous 
(mucous,  colloid,  m^-xomatous)  in  fibroma,  chondroma,  and  sarcoma, 
as  well  as  in  adenoma  and  glandular  cancer,  we  must  alwaj^s  ob- 
serve very  particularly  what  we  have  before  us :  frequently  we  shall 
be  in  doubt  about  the  significance  of  the  histological  elements,  aa 
well  as  about  the  proper  name. 

The  only  treatment  is  removal  of  the  tumor,  if  it  can  be  done 
without  endangering  life.  Of  course  we  would  not  interfere  with  the 
chondromata  of  the  pelvis,  which  are  usuallj'-  very  large  ;  those  of  the 
thigh,  which  are  generally  very  large  when  the  patient  applies  for 
treatment,  can  only  be  gotten  rid  of  by  exarticulation  of  the  femur, 
and  we  should  scarcely  do  this  before  spontaneous  fracture  of  the 
extremity,  from  disease  of  the  bone,  has  rendered  it  useless.  Chon- 
dromata of  the  fingers  are  most  frequently  subjects  for  operation,  not 
because  they  are  painful,  for  they  are  usually  free  from  pain,  but  be- 
cause they  impair  the  function ;  this  takes  place  very  slowly  and 
gradually,  hence  the  tumors  will  have  attained  a  considerable  size. 
So  long  as  the  patients  can  use  their  nodulated  swollen  fingers,  they 
neither  urge  the  operation,  nor  can  we  urgently  adviee  them  to  sub- 
mit to  it.  As  regards  the  mode  of  operation,  in  many  cases  where 
the  tumor,  even  if  firmly  adherent  to  the  bone,  is  seated  laterally,  it 
Avould  be  natural  to  try  di\'iding  the  skin,  and  pushing  it  and  the 
tendons  to  one  side,  then  remoWng  the  tumor  with  the  knife  or  saw. 
But  this  is  rarely  practicable,  if  we  would  remove  the  entire  tumor, 
which  is  imperatively  necessary  ;  for  often  the  cartilaginous  mass  en- 
tirely pervades  the  medullary  cavity  of  the  bone.  Moreover,  after 
such  an  operation,  there  may  be  severe  inflammation  of  the  sheath  of 
the  tendon,  as  a  result  of  which  the  finger  may  remain  stiff.  There 
have  not  been  enough  careful  observations  to  verify  DieffenhacKs 
assertion,  that  any  remnants  of  the  chondroma  that  may  be  left  ossify 
and  become  stable ;  hence  the  removal  of  chondroma  from  bone 
should  be  limited  to  few  cases,  and  to  those  where  the  tumor  is  still  I 

small.     If  the  tumors  have  attained  a  considerable  size,  we  postpone  ' 

exarticulation  of  the  fingers  to  a  time  when  the  tumors  shall  have  i 

rendered  the  hand  entirely  useless. 


4.  OSTEOMATA— EXOSTOSES. 


By  this  term  we  designate  abnormally-formed  masses  of  bone, 
which  are  circumscribed,  and  have  an  independent  growth,  not  de- 
pending on  a  chronic  inflammation.  Formation  of  bone  also  occurs 
occasionally  in  other  tumors,  especially  in  those  forming  in  bone,  as 


TUMORS. 


699 


we  have  already  remarked  when  speaking  of  chondroma.  But  the 
name  osteoma  is  usually  limited  to  tumors  consisting  entirely  of  bone. 
I  may  mention  here  that  not  only  new  formations  of  entire  teeth 


FiQ.  1-23. 


Orlontcma  of  a  hack  tooth, 
uatural  size. 


Section  of  an  odontoma.    Mamifled  100  diameters. 


(very  irregularly  shaped)  occur  in  ovarian  cysts  and  in  the  antrum 
Highmori,  but  that  on  the  teeth  themselves  outgrowths  of  true  ivory 
iiiatter,  ivory  exostoses  (odontoma  of  Virchow)  have  been  observed ; 
but  these  are  very  rare,  and  may  be  regarded  merely  as  curiosities. 
Exostoses  consist  partly  of  spongy  bone-substance,  like  that  in  the 
medullary  cavity  of  bones,  partly  of  ivory-like  substance,  like  that  in 
the  regular  lamella?  of  the  cortical  substance  of  the  hollow  bones ; 
hence  we  shall  distinguish  spongy  exostoses  and  ivory  exostoses.  A 
third  form  of  osteomata  is  formed  by  the  ossification  of  tendons,  fas- 
cite,  and  muscles,  whose  right  to  be  classed  among  tumors  is,  how- 
ever, doubtful. 

{a.)  Spongy  exostoses,  with  cartilaginous  covering  (exostosis  car- 
tilaginae).  These  tumors  occur  almost  exclusively  on  the  epiphyses 
of  the  long  bones  ;  they  are  outgrowths  from  the  epiphyseal  cartilages, 
whence  Virchow  very  properly  calls  them  "  Ecchondrosis  ossificans*'* 


lOO 


OSTEOMATA. 


(Fig.  124).  On  tlieir  roundish,  nodular  surface,  there  is  a  layer  of 
beautifully-developed  hyaline  cartilage,  about  a  line  or  a  line  and  a 
half  thick,  which  evidently  grows  partly  in  itself,  partly  peripherally 
from  the  periosteum  or  perichondrium,  then  rapidly  ossifies  toward  tlie 
centre.     The  newly-formed  bony  mass  itself  is,  from  its  start,  most 

Fig.  124. 


Pedixncnlated  spongy  cxostoeis  from  the  lower  end  of  the  femur,  after  Pean. 


intimately  connected  with  the  spongy  substance  of  the  epiphyses,  so 
that  the  hard  tumor  is  immovably  seated  on  the  bone.  From  the  na- 
ture of  these  exostoses  they  can  only  occur  in  young  persons.  Ac- 
cording to  my  observation,  tibia,  fibula,  and  humerus,  are  their  most 
frequent  seat. 

{b.)  Ivory  exostoses.  These  consist  of  compact  bony  substance, 
with  Haversian  canals  and  lamellar  systems;  they  develop  on  the 
bones  of  the  face  and  skull  (Figs.  125  and  126),  on  the  pelvis,  scapula, 
grert  toe,  etc.,  and  form  roundish,  nodiJated,  or  smooth  tumors. 


TUMORS. 


701 


A  third  variety  of  tumor-like  formation  of  bone  is  the  abnormal 
ossification  of  tendons,  fascia?,  and  muscle,  which  usually  occurs  on  a 


Fig.  125. 


m 


y 


^p^^ 


Ivory  exostosis  of  tlie  skull. 


series  of  tendons  and  fasciae  after  they  have  previously  ossified  a  great 
deal,  so  that  the  skeleton  of  such  patients,  who  are  generally  youn<r, 


Fig.  12fi. 


."Section  from  nu  ivory  oi^tc'inu  ol  Uie  t-kuu. 


702 


OSTEOMATA. 


are  covered  with  twenty  to  fift}'  long,  sharp,  bony  processes,  where 
the  tendons  are  attached  to  the  bone  (Fig.  -p^^  ^27. 

137) ;  as  in  one  case  observed  in  Zurich, 
the  ossification  occasionally  occurs  in  the 
fascia  of  the  muscle.  Cases  have  been  ob- 
served where  this  ossification  was  so  exten- 
sive that  all  the  muscles  of  the  shoulder 
and  arm  were  ossified,  and  the  upper  ex- 
tremity could  not  be  moved.  These  boin- 
neoplasias,  as  well  as  the  so-called  exercise^ 
bones,  must  doubtless  be  regarded  as  the 
product  of  chronic  inflammation,  just  like 
the  true  bony  formations  that  are  abnor- 
mally developed  in  the  membranes  of  the 
brain  and  spinal  medulla.  By  exercise- 
bones  we  mean  the  development  of  bone 
in  the  deltoid  muscle,  particularly  at  those 
points  where  the  musket  strikes  when  drill- 
ing. But  these  bones  form  in  few  sol- 
diers, and  their  development  presupposes 
a  tendency  to  the  formation  of  bone.  Os- 
sification of  the  tendons,  especially  of  their 
points  of  attachment  to  the  bone,  which 
occasionally  occurs  from  some  unknown 
cause,  is  also  very  remarkable,  and  reminds 
us  of  a  similar  process  in  birds,  which  in 
them  is  perfectly  normal. 

The  predisposition  to  formation  of  os- 
teomata  is  allied  to  that  for  development  of 
chondromata ;  it  also  occurs  more  frequent- 
ly in  the  young,  and  in  men  than  in 
women,  while  children  almost  escape  it. 
As  regards  epiphyseal  osteomata,  which  might  be  termed  ossifying 
chondromata,  they  of  course  cannot  occur  later  than  the  twenty- 
fourth  year.  But  other  exostoses  also  occur  generally  before  the  thir- 
tieth year ;  observations  on  this  point  are  not  very  numerous,  as  the 
disease  is  rare.  This  experience  about  the  occurrence  of  osteomata  in 
the  young  is  the  more  remarkable,  as  it  stands  in  a  certain  contrast  to 
the  general  rule  of  ossification  being  especially  apt  to  occur  in  old 
persons.  The  cartilages  of  the  ribs  and  larynx  and  the  spinal  liga- 
ments often  ossify  in  advanced  age ;  the  chalky  deposits  in  the  ar- 
teries of  the  aged  also  form  part  of  the  almost  natural  senile  maras- 
mus ;  development  of  osteomata,  however,  rarely  occurs  in  old  persons, 


Osteoma  of  thp  mnsciilar  attach- 
ments, after  0.  Weber. 


TUMORS.  703 

but  when  such  tumors  are  found  in  them  they  have  usually  dereloped 
in  youth.  Osteomata  are  just  as  often  multiple  as  solitary;  their 
growth  is  generally  very  slow,  and  is  usually  arrested  with  advancing 
age.  The  growth  of  epiphyseal  exostoses  ceases  after  the  skeleton 
has  completed  its  growth,  and  its  spongy  substance  becomes  more 
compact.  Ossification  of  the  tendons  and  muscles  rarely  goes  so  far 
as  to  entirely  prevent  motion.  In  some  cases  development  of  bone 
has  been  observed  in  the  lung.  The  inconveniences  caused  by  osteo- 
mata are  not  usually  great ;  their  development  is  not  accompanied  by 
pain,  nor  are  they  sensitive  to  the  touch ;  but  osteomata  in  the  vicin- 
ity of  joints  often  impair  their  function.  When  these  tumors  occur 
on  the  bones  of  the  face,  they  cause  unpleasant  deformities  ;  exostoses 
on  the  big-toe  prevent  wearing  the  shoe ;  ossification  of  the  tendons 
and  muscles  impairs  or  entirely  prevents  motion ;  but  unfortunately, 
from  their  size  and  number,  operative  surgery  can  do  little  for  the  lat- 
ter, and  the  less  so,  as  the  tendency  to  morbid  development  of  bone 
still  continues.  The  operation  for  exostosis  consists  in  sawing  or 
chiselling  the  tumor  from  the  bone  aiFected.  But,  as  the  latter  is 
occasionally  in  the  vicinity  of  a  joint,  the  articulation  might  thus  be 
opened  ;  it  is  neither  advisable  nor  necessary  to  undertake  such  opera- 
tions unless  the  impairment  of  function  be  so  great  as  to  balance  an 
operation  dangerous  to  the  joint  and  to  life.  We  should  be  the  less 
inclined  to  undertake  such  ojoerations  without  some  special  indication, 
as  in  the  course  of  time  these  tumors  cease  to  grow.  On  epiphyseal 
exostoses  we  occasionally  find  mucous  bursae  containing  adherent,  or 
loose  ossifying  chondromata ;  these  mucous  bursa3  usually  communi- 
cate with  the  joint  in  whose  vicinity  the  exostosis  is  situated.  Ac- 
cording to  the  investigations  of  liindfleiscJi,  the  mucous  bursas  are 
always  abnormal  elongations  of  the  pockets  of  the  articular  sj-novial 
membrane.  I  once  allowed  myself  to  be  induced,  by  the  entreaties 
of  a  patient,  to  remove  such  an  exostosis  on  the  lower  end  of  the 
femur  with  a  large  mucous  biu"sa;  the  patient  died  of  septicremia. 
In  another  case  the  mucous  bursa  over  an  exostosis  on  the  lower  end 
of  the  humerus  opened  spontaneously  after  moderate  inflammation  j 
there  was  suppuration  of  the  elbow-joint,  with  anchylosis ;  the  patient 
would  not  permit  resection  of  the  joint. 

[It  would  seem,  from  observations  of  English  surgeons  in  China, 
that  elephantiasis  Arabum  depends  on  the  filaria  sanguinis  hominis, 
which  enters  the  system  by  the  drinking-water  and  probably  takes 
up  its  position  somewhere  in  the  lympliatic  system.  Patients  with 
elephantiasis  GraBcorum  are  also  said  to  have  a  peculiar  bacillus  in 
the  blood.] 


7j4  tumors. 


LECTURE    XLVII. 

5.  Myoma. — 6.  Neuroma. — 7.  Angioma:  a,  Plexiform  ;  />,  Cavernous. — Operations. 

5.   MYOMATA. 

At  present  it  remains  iindecitled  whether  there  are  pure  myo- 
mata,  i.  e.,  tumors  consisting  entirely  of  transversely-striated  mus- 
cle-filaments or  their  cells  ;  I  do  not  know  that  any  such  have  been 
observed.  The  occurrence  of  newly-formed  transversely-striated 
muscle-filaments  has  been  very  rarely  observed  in  tumors.  No 
tumor  was  ever  entirely  composed  of  them  ;  they  were  usually  an 
accidental  occurrence  in  sarcoma  or  carcinoma  (of  the  testicle, 
ovary,  or  mamma),  or  in  tumors  of  very  complicated  formation  ; 
according  to  the  latest  observation,  they  are  most  frequent  in  sar- 
comatous tumors  of  the  kidneys  in  children.  I  have  examined 
tumors  in  Avhich  there  were  distinct  stages  of  development  of  mus- 
cular filaments,  but  the  right  of  classing  such  tumors  as  myomata 
has  been  disputed.  I  can  say  little  against  this,  as  we  cannot  call 
tumors,  consisting  of  grades  of  development  of  connective  tissue, 
fibromata,  and  as  I  formerly  objected  (page  685)  to  terming  uterine 
fibromata,  composed  of  spindle-cells,  myomata,  as  we  are  not  quite 
sure  of  the  relation  of  spindle-cells  to  muscle-cells.  In  old  men, 
extensive  newly-formed  smooth  muscles  occur  in  the  prostate, 
partly  as  independent  nodules,  partly  as  diffuse  enlargements  of  the 
organ.  There  is  certainly  no  objection  to  terming  these  so-called 
prostatic  hypertrophies  (there  is  usually  some  coincident  gland  nlar) 
myoma  ;  similar  myoma-nodules  are  met  in  the  muscular  coat  of 
the  oesophagus  and  stomach.  I  have  often  removed  from  the  blad- 
ders of  young  persons  true  myomata,  of  flat  muscle-filaments  (myo- 


NEUROMATA.  705 

ma  Iffivicularse),  sometimes  with  pedicles  ;  they  seem  to  arise  from 
the  muscular  coat  of  the  bladder.  Clinically,  nothing  certain  can 
be  said  of  myomata  in  these  conditions  ;  the  tumors  which  I  con- 
sidered as  young  myomata  in  the  muscles  had,  on  section,  a  medul- 
lary fascicular  appearance,  an  insuperable  tendency  to  local  recur- 
rence, and  thus  caused  death. 

6.   NEUEOMATA. 

It  has  already  been  mentioned  (page  088)  that  the  name  "  neu- 
roma "  is  often  a^jplied  to  tumors  occurring  on  the  nerves  ;  this  is, 
if  you  please,  a  practical  misuse,  which,  however,  it  is  difficult  to 
root  out.  By  "  true  neuroma  "  we  mean  a  tumor  composed  en- 
tirely of  nerve-filaments,  especially  of  those  with  double  contours  ; 
they  appear  to  come  only  on  nerves,  and  are  very  rare.  Neuro- 
mata in  amputation-stumps  have  already  been  mentioned  (page 
125)  ;  many  doubt  whether  there  are  any  other  true  neuromata. 
True  neuromata  are  always  very  painful.  Many  of  the  fibromata 
on  and  in  nerves  contain  very  peculiar  bundle-like  fine  filaments 
richly  supplied  with  nuclei,  which  may  very  well  be  taken  for  gray 
filaments  containing  no  medulla,  as  Yirchow  considers  them  ;  this 
would  make  true  neuromata  a  large  class,  and  divide  them  into 
myeline  and  amyeline  forms.  I  do  not  always  trust  myself  to  dis- 
tinguish an  amyeline  neuroma  from  a  fibroma  in  a  nerve,  and  hence 
should  not  require  it  of  others.  Tumors  composed  of  spindle-cells 
arranged  in  bundles  are  probably  far  oftener  young  myomata  and 
neuromata  than  young  fibromata,  but  it  would  be  difficult  to  prove 
to  which  class  they  belong.  Multiplicity  and  tendency  to  regional 
recurrence  are  peculiar  to  neuromata,  hence  the  prognosis  should 
always  be  guarded.  It  is  rarely  possible  to  dissect  a  neuroma  from 
the  nerve  ;  part  of  the  latter  must  generally  be  removed  with  it. 

[Diffuse  thickenings  of  all  the  twigs  of  a  nerve-plexus  are  not 
very  rare,  and  are  called  plexiform  neuromata  ;  they  are  sometimes 
accompanied  by  elephantiasis-like  thickening  of  the  skin  and  subcu- 
taneous tissue  of  the  parts  supplied  by  the  affected  nerve  (  Czerney). 
Although  the  greater  part  of  the  plexiform  neuroma  is  newly-formed 
connective  tissue,  still,  young  nerve-filaments  are  found  through  it ; 
sometimes  some  of  the  nodules  of  a  plexiform  neuroma  have  entirely 
the  character  of  a  rapidly-growing  sarcoma,  with  metastases  to  in- 
ternal organs.  "VVe  may  distinguish  two  types  of  neuromata,  those 
that  come  multiple  on  cerebral  and  spinal  nerves,  somewhat  resem- 
bling fibromata,  and  solitary  neuroma  often  mistaken  for  sarcoma. 
While  in  the  new  neuromata  we  have  described  there  were  no  nerve- 
cells,  only  nerve-filaments,  in  some  tumors  of  the  brain  and  medulla 
46 


706  TUMORS. 

oblongata  we  find  new  ganglion-cells.  Quite  lately  Axel  Key  ob- 
served the  same  iu  a  tumor,  the  size  of  a  plum,  that  originated  from 
the  infraorbital  nerve.  In  the  soft  tissue  whose  gross  features  were 
those  of  a  sarcoma,  he  found  numerous  elements  resembling  gan- 
glion-cells ;  but  this  is  rare. 

In  neuroma  the  prognosis  should  be  reserved  ;  operations  should 
only  be  done  when  the  tumor  grows  rapidly  or  is  very  painful ;  if 
it  is  necessary  to  cut  out  part  of  the  nerve,  the  ends  should  be  sewed 
together  if  possible,  or  we  may  transplant  portions  of  a  nerve  from 
some  animal.  This  operation  has  succeeded  experimentally  ;  whether 
it  would  do  so  in  man  is  a  question  worth  deciding.] 

7.  ANGIOMATA— VASCDLAE  TCMOKS. 

By  this  term  we  mean  tumors  composed  almost  exclusively  of  ves- 
sels held  together  by  a  sliglit  amount  of  connective  tissue ;  they  have 
also  been  called  [noevi,  mother's-marks]  "  erectile  tumors,"  being  firm- 
er or  softer,  larger  or  smaller,  according  to  the  fulness  of  the  vessels. 
The  ordinary  forms  of  varicose  dilatations  of  the  veins  and  the  aneu- 
risms of  different  arteries  are  excluded  by  this  definition.  But  circoid 
aneulism  and  some  forms  of  aneurismal  varix  might  be  classed  here ; 
yet,  as  this  is  not  customary,  we  treated  of  these  diseases  earlier. 
Here  we  have  to  consider  two  different  varieties  of  vascular  tumors : 

(a.)  T\\Q  plexiform  angioma  ox  telangiectasis  (from  rfAof,  ayyecov, 
sKTaaig).  This  is  the  most  frequent  form  ;  this  neoj^lasia  is  composed 
entirely  of  dilated  and  tortuous  capillaries,  and  anastomosing  vessels, 
and,  according  as  the  proliferation  of  the  vessels  or  the  pure  ectasia 
predominates,  it  appears  more  as  a  tumor  or  as  a  red  spot  on  the 
skin.  Plexiform  angiomata,  of  the  variety  we  are  about  to  describe, 
occur  almost  exclusively  in  the  cutis.  They  have  sometimes  a  dark- 
cherry,  at  others  a  steel-blue  color ;  are  sometimes  as  large  as  a  pin- 
head,  again  as  large  as  a  hemp-seed ;  some  are  moderately  thick, 
others  scarcely  rise  above  the  level  of  the  skin.  There  are  very  rare 
forms  where  there  is  not  a  red  spot  or  a  tumor,  but  a  diffuse  redness 
over  a  large  surface  ;  in  such  cases,  even  with  the  naked  eye,  we  usu- 
ally see  the  distended  and  looped  fine  vessels  on  the  surface  of  the 
cutis,  showing  through  the  epidermis.  Anatomical  examination  of 
large  extirpated  angiomata  of  this  variety  shows  that  they  are  com- 
posed of  smaU  lobuli  as  large  as  a  hemp-seed  or  a  pea ;  and,  if,  after 
artificial  injection  or  other  mode  of  preparation,  we  examine  them 
microscopically,  we  shall  find  that  these  lobuli  are  formed  by  the  ves- 
sels of  the  sweat-glands,  hair-folhcles,  fat-glands,  and  fat-lobuli,  being 
independently  diseased,  and  that  the  different  small  proliferating,  vas- 
cular systems  form  the  above-mentioned  lobuli,  which  are  visible  to 


ANGIOMA  TA. 


707 


the  naked  eye.  Tlie  reason  for  the  color  of  these  tumors  being  some- 
times blood-red,  sometimes  pale  bluish,  is  that,  in  the  former  case,  the 
capillaries  of  the  most  superficial  layer  of  cutis,  in  the  second,  the 
deeper  vessels,  are  diseased.  As  a  rule,  this  proliferation  of  vessels 
does  not  go  beyond  the  subcutaneous  cellular  tissue  ;  rarely  it  affects 
the  deeper  tissues,  such  as  the  muscles  ;  whence  it  appears  that  these 
neoplasiae  not  only  grow  centrally,  but  especially  peripherally,  and 
destroy  the  part  affected.     Most  of  these  tumors  may  be  slowly  emn- 

Pig.  128. 


Coufclomeration  of  vessels  from  a  plexiform  aiip;ioma.  Matrnified  60  diameters,  a,  proliferating 
vascular  net-work  around  a  sweat-gland  (which  is  not  sliown,  to  prevent  complicatinir  the 
drawing)  ;  6,  proliferating  vascular  iiet-vvork  in  the  papillse  of  the  oral  mucous  membrane. 

tied  by  pressure,  and  again  fill  as  soon  as  the  pressure  ceases.  But 
there  are  also  moderate-sized  telangiectases,  in  which,  besides  the 
proliferation  of  vessels,  there  is  also  a  new  formation  of  connective 
tissue  and  fat,  so  that  they  cannot  be  entirely  removed  by  pressure. 
Wlien  these  new  formations  were  superficial  in  the  cutis,  and  the 
blood  has  been  emptied  from  them  after  extirpation,  Avith  the  naked 
eye  we  can  hardly  see  any  thing  abnormal  in  the  morbid  piece  of  skin 
that  has  been  removed ;  a  moderate  neoplasia  of  this  variety  appears 
on  the  cut  surface  as  a  pale-reddish,  soft,  lobulated  substance,  in  which 
we  can  see  no  vessels  with  the  naked  eye,  because  the  whole  disease 
is  usually  limited  to  the  capillaries  and  minute  vessels,  and  to  a  few 
small  arteries. 


V08 


TUMORS. 


(b.)  Cavernous  angiomata^  or  cavernous  venous  tremors.  We  will 
first  determine  their  anatomy,  so  that  you  may  at  once  correctly  note 
their  difference  from  plexiform  angiomata.  Extirpated  cavernous 
angiom'ata  may  at  once  be  recognized,  on  section,  by  having  almost 
exactly  the  formation  of  the  corpus  cavernosum  penis.  You  see  a 
white,  firm,  tough  net-work,  which  apj^ears  empty,  or  at  least  con- 
tains only  in  spots  red  or  discolored  coagula,  or  possibly  is  filled  with 
small,  round,  chalky  concrements,  so-called  vein-stones  ;  but  w^e  must 
imagine  the  mesh-work  as  distended  with  blood  previous  to  its  extir- 
pation. Tlie  boundary  of  this  cavernous  tissue,  which  may  form  in  all 
the  tissues  of  the  body,  is  sometimes  evidently  a  sort  of  capsule ;  but 
in  other  cases  this  cavernous  degeneration  is  very  indistinctly  bounded, 
and  at  different  spots,  in  a  rather  indifferent  manner,  it  enters  the 
tissue.  3ficroscopic  examination  of  this  mesh-work,  which  is  formed 
sometimes  of  thin  threads,  sometimes  of  membrane-like  capsules, 
shoAvs  that  the  branches  are  formed  of  remains  of  the  tissue  in  which 

FiQ.  129. 


Mesh-work  from  a  cavemons  ansioma  of  tne  lip  (the  blood  is  to  be  imagined  in  the  large  meshes 
between  the  net-work).    Magnified  350  diameters. 


the  cavernous  ectasia  occurs.  The  inner  wall  of  the  space  filled  with 
blood  is,  in  most  cases,  coated  with  spindle-shaped  cells  (venous  endo- 
thelium), so  that  even  these  anatomical  conditions  go  to  prove  that  we 
liave  to  deal  chiefly  with  distended  veins.  The  mode  of  development 
of  this  peculiar  tissue  has  received  different  explanations. 

If  we  had  any  accurate  investigations  about  the  development  o'' 


ANGIOMATA.  709 

the  cor}3us  cavernosum  penis,  we  miglit  draw  some  definite  conclusions 
from  them,  on  account  of  the  great  analogy  of  the  two  tissues.  The 
three  chief  hypotheses  about  the  development  of  cavernous  tumors 
are  as  follows:  1.  It  is  asserted  that  the  cavernous  spaces  first  develop 
from  the  connective-tissue,  and  secondarily  become  connected  witli 
the  vessels ;  and  it  has  even  been  suggested  that  blood  might  be  de- 
veloped outside  of  the  circulation,  from  the  derivatives  of  the  connec- 
tive-tissue cells ;  the  striae  of  the  mesh-work  would  increase  by  inde- 
pendent growth,  by  sprouting,  and  club-shaped  growth  of  the  connec- 
tive tissue  {Bokitansky).  This  hypothesis,  especially  the  formation 
of  blood  outside  of  the  circulation,  has  some  objections.  2.  It  is 
asserted  that  circumscribed  dilatations  of  small  veins  occur  close  to- 
gether, and  that  at  the  points  where  they  come  in  contact  the  walls 
are  gradually  thinned  or  entirely  disappear.  This  view  is  supported 
by  the  fact  that  these  gradual  distentions  of  the  veins  may  occasion- 
ally be  distinctly  followed  out  both  in  the  cutis  and  bones  when  these 
tumors  are  developing.  3.  HindfleiscJi  claims  that  vascular  ectasia, 
especially  in  the  cavernous  tumors  which  form  in  the  orbital  fat,  is 
always  preceded  by  infiltration  of  the  tissues  with  small  cells,  which 
is  followed  by  a  sort  of  cicatricial  shrinking  of  the  tissue,  and  conse- 
quent tearing  apart  of  the  vessels,  whose  calibre  must  constantly  be 
increased  by  continued  atrophy  of  tlie  intermediate  tissue. 

For  some  reasons  I  have  long  supposed  that  both  in  plexiform  and 
cavernous  angiomata  there  was  some  process  similar  to  inflammation, 
but  neither  the  latter  (scarcely  applicable  to  the  cavernous  tumors  in 
bones)  nor  the  former  two  hypotheses  appear  to  fully  explain  the 
causes  and  peculiar  differences  in  the  distention  of  the  vessels.  We 
have  still  to  mention  one  difference  between  cavernous  tumors  :  they 
are  either  connected  with  the  large  venous  trunks,  as  sacs  to  the  sub- 
cutaneous veins,  or  numerous  small  arteries  and  veins  sink  into  the 
capsule  of  the  cavernous  tissue.  Lastly  we  must  mention  that  these 
cavernous  venous  ectasias  may  occur  accidentally  in  other  tumors  as  in 
fibroma  and  lipoma,  as  has  already  been  mentioned.  A  few  years 
since  I  extirpated  a  lobular  lipoma,  which  had  formed  below  the 
scapula  of  a  vigorous  young  man,  all  of  the  lobes  of  which  had 
centrally  degenerated  to  cavernous  tissue.  Cavernous  angiomata  de- 
velop with  especial  frequency  in  the  subcutaneous  cellular  tissue, 
more  rarely  in  the  cutis  and  muscles,  very  rarely  in  bones,  but  quite 
often  in  the  liver,  particularly  on  its  surface,  occasionally  also  in  the 
spleen  and  kidneys.  They  are  sometimes  quite  painful,  other  cases 
are  not  at  all  so. 

The  diagnosis  of  cavernous  angiomata  is  not  always  easy ;  when 
iliey  occur  in  the  cutis,  they  may  be  mistaken  for  more  deeply-seated 


710  TUMORS. 

telangiectases,  although  the  blood  may  be  pressed  out  of  the  cavernous 
v^enous  tumors  more  readily  than  from  telangiectases.  Deeply-seated 
tumors  of  this  sort  are  always  difficult  to  recognize  with  certainty; 
the}'  usually  show  decided  fluctuation,  are  somewhat  compressible, 
swell  on  forced  expiration ;  but  the  last  two  symptoms  are  not  always 
distinct,  hence  they  may  readily  be  mistaken  for  lipomata,  c^^sts,  and 
other  soft  tumors ;  sometimes,  indeed,  this  mistake  cannot  be  avoided. 

Probably  half  the  angiomata  are  congenital,  or  at  least  developed 
soon  after  birth.  If  they  develop  during  life,  it  is  usually  in  childhood 
or  youth ;  it  is  rare  for  vascular  tumors  to  occur  during  manhood  or 
old  age,  which  is  very  remarkable,  as  the  disposition  to  vascular  dis- 
eases, especially  to  ectasia  of  the  vessels,  greatly  increases  with  ad- 
vanced age.  Not  only  the  larger  arteries  and  veins  dilate  at  this 
time,  but  also  the  small  anastomosing  vessels  and  capillaries,  at  certain 
localities,  show  visible  dilatations  through  the  sldn.  On  the  face  of 
a  ruddy,  healthy  old  man  we  see  red  cheeks  as  we  do  in  the  young; 
it  is  not,  howev^er,  the  regular  rosy  bloom  of  a  maiden's  cheek,  but 
a  more  bluish  red,  and,  if  you  look  more  closely,  you  find  numerous 
tortuous  vessels,  visible  to  the  naked  eye ;  in  some,  this  redness  occurs 
in  spots.  Tliese  small  vascular  ectasiie  do  not  occur  in  all  old  persons, 
so  that  we  must  suppose  them  due  to  a  peculiar  predisposition.  Hence, 
as  we  said,  in  spite  of  the  fact  that  advanced  age  is  more  disposed  to 
disease  of  the  vessels  than  any  other  time  of  life,  true  vascular  tumors 
develop  almost  exclusively  in  youth.  There  is  no  doubt  that  the  te- 
langiectasise,  which  popularl}'-  are  often  called  "  mother's-marks,"  are 
often  inherited.  This  appears  to  be  proved  by  a  number  of  stories 
about  children,  that  have  been  lost,  being  subsequently  recognized  by 
marks  inherited  from  the  father  or  mother.  We  should  undoubtedly 
learn  far  more  of  the  hereditary  transmission  of  vascvilar  tumors  if  we 
would  attend  more  to  that  of  diseases  of  the  vessels  generally.  Even 
if  plexiform  and  cavernous  angiomata  are  to  be  regarded  as  anatomi- 
cally distinct  from  each  other,  and  from  the  different  varieties  of  va- 
rices and  aneurisms,  it  is  still  clear  that  a  predisposition  to  dilatation 
of  the  vessels  is  at  the  root  of  all  of  them ;  this  is  undoubtedly  to  a 
great  extent  inherited,  and  the  above  diseases  can  only  be  regarded 
as  different  modes  of  appearance  of  this  predisposition  at  different 
ages.  Hitherto  attention  has  been  so  exclusively  paid  to  the  ana- 
tomical conditions  of  the  tumors  that  the  classes  of  diseases  accom- 
panying them  have  been  too  little  noted. 

As  regards  the  further  fate  of  angioma,  telangiectasi^e,  which  are 
almost  always  congenital,  may  be  either  solitary  or  multiple.  Their 
growth  is  always  slow,  painless,  and  is  sometimes  chiefly  superficial 
again  in  the  depth,  and  usually  at  the  expense  of  the  diseased  tissue. 


ANGIOMATA.  7lj 

There  is  no  doubt  that  occasionally  in  the  course  of  j-ears  these  tumors 
cease  to  grow,  but  remain  unchanged.  But  in  other  cases  the  growth 
continues  so  that  the  tumors,  as  I  once  saw  on  the  neck  of  a  boy  five 
years  old,  may  grow  almost  as  large  as  a  man's  fist.  Frequently  two 
or  three  telangiectases  occur  congenitally,  or  occur  in  quick  succes- 
sion, especially  on  the  scalp,  more  rarely  there  are  six  or  eight.  I 
have  seen  two  cases  of  flat  congenital  plexiform  angiomata  of  the  left 
side  of  the  face,  which  healed  at  some  points,  partly  from  ulceration, 
partly  from  unknown  causes;  i.  e.,  cicatricial  white  spots  occurred  here 
and  there,  where  the  vessels  were  obliterated,  while  in  the  peripherv 
the  proliferation  progressed. 

Cavernous  angiomata  are  rarely  congenital,  but  generally  occur  in 
childhood  or  youth,  more  rarely  later  in  life.  As  akeady  remarked, 
their  seat  is  chiefly  in  the  subcutaneous  cellular  tissue,  .more  frequent- 
ly in  the  face,  more  rarely  on  the  trunk  and  extremities.  They 
often  occur  in  large  numbers,  but  in  such  a  way  that  a  certain  vas- 
cular district  is  to  be  regarded  as  the  seat  of  disease,  as  an  arm,  a 
foot,  leg,  or  face,  etc.  Besides  the  disfigurement,  the  symptoms  in- 
duced are  a  certain  weakness  of  the  muscles,  and  occasionally  pain  in 
the  part  afifected.  Tlie  tumors  may  attain  considerable  size,  and  thus 
especially  on  the  head  prove  dangerous,  the  more  so,  as  by  further 
progress  they  enter  and  destroy  the  bone.  Some  observations  that  L 
know  of  show  that  in  these  tumors,  as  a  result  of  thrombosis  of  the 
cavernous  spaces,  there  may  be  atrophy  and  retrogression  (especially 
in  the  cavernous  tumors  of  the  liver)  ;  but  complete  disappearance  of 
the  angioma  by  spontaneous  obliteration  has  not  been  observed. — 
Treatment  for  vascular  tumors  is  very  varied.  The  operations  have 
two  difi"erent  objects : 

1.  Methods  aiming  at  coagulation  of  the  blood,  with  consequent 
obliteration  and  atrophy  of  the  tumor.  Among  these  are  injecting 
the  tumor  with  liquor  ferri  sesquichlorati ;  also  transfixing  them 
with  hot  needles,  or  the  galvano-cautery,  and  drawing  a  platinum  Avire 
through,  and  subsequently  heating  it  with  the  galvano-caustic  appa- 
ratus (galvano-caustic  setaceum).  We  must  also  mention  continued 
compression  of  the  tumor  and  ligation  of  the  afi"erent  artery.  Both  of 
the  latter  have  gone  out  of  use,  as  they  have  proved  entirely  worthless. 

2.  Methods  aiming  at  the  removal  of  the  angioma  : 

[a.)  By  ligation ;  in  telangiectasis  with  a  broad  base  this  must 
be  double  or  multiple.  A  needle  with  a  double  ligature  is  passed 
through  under  the  tumor ;  one  ligature  is  tied  to  one  side,  the  other 
to  the  other  side  of  the  base  of  the  tumor. 

(5.)  In  vaccinating  on  the  tumor,  so  that,  when  tlie  vaccine  scab 
^alls,  the  tumor  may  be  removed. 


712  TUMORS. 

(c.)  Cauterization  ;  for  this  purpose  fuming  nitric  acid  is  best;  it 
shoiild  be  applied  by  a  rod  about  as  thick  as  a  goose-quill,  till  the 
angioma  assumes  a  yellowish-green  color. 

(d.)  By  extirpation  -with  the  scissors  or  knife. 

After  some  experience  in  operating,  the  choice  of  these  methods 
in  any  given  case  is  not  difficult.  In  superficial  angiomata,  if  not  al- 
too-ether  too  extensive,  and  not  so  situated  that  the  subsequent  cica- 
tricial contraction  would  cause  decided  deformity,  as  on  some  parts 
of  the  face,  I  regard  cauterization  with  fuming  nitric  acid  as  the  proper 
method.  In  extensive  plexiform,  and  in  the  cavernous  angiomata,  re- 
moval with  the  knife  and  scissors  is  the  most  certain  operation.  Too 
profuse  haemorrhages  in  such  operations  may  be  prevented  partly  by 
compression  of  the  parts  around  by  skilled  assistants,  and  the  rapid 
application  of  the  suture,  partly  by  free  mediate  ligation  of  the  whole 
periphery  of  the  tumor.  In  many  cases  of  angioma  of  the  face  also 
extirpation  is  to  be  preferred  to  cauterization,  because  the  incision 
may  be  so  directed  that  the  subsequent  cicatricial  contraction  shall 
induce  no  distortion  of  the  eyelids  or  angle  of  the  mouth.  But  there 
are  cases  where  extirpation  is  entirely  impracticable,  partly  from  the 
size,  partly  fiom  the  seat  or  number  of  such  tiunors.  I  treated  a 
child,  with  a  still  growing  cavernous  tumor  which  extended  from  the 
glabella,  through  the  nose  and  whole  upper  lip.  If  it  had  been  de- 
sired to  extirpate  this,  it  would  have  been  necessary  to  remove  the 
whole  nose  and  upper  lip ;  of  course,  this  was  not  to  be  thought  of; 
hence  I  tried  cauterization  with  heated  needles.  The  treatment  had 
lasted  three  months,  and  would  have  taken  as  much  longer,  although 
a  large  part  of  the  cavernous  space  was  already  obliterated,  when  the 
mother  of  the  child  unfortunately  lost  patience,  and  I  never  saw  it 
again.  I  prefer  this  mode  of  cauterization  to  the  injection  of  liquor 
ferri,  as  suppuration  and  gangrene  occasionally  follow  the  latter,  and 
as  the  injection  is  occasionally  rendered  difficult  by  the  fine  canula 
being  stopped  by  coagulu.  The  other  methods  are  of  very  secondary 
importance ;  vaccination  frequently  does  not  go  deep  enough,  and  the 
ligature  is  a  tedious,  uncertain  method,  which  is  sometimes  rendered 
dangerous  by  secondary  hoemorrhage, 

[In  regard  to  the  formation  of  blood  outside  of  the  circulation,  as 
an  explanation  of  cavernous  angioma,  of  late  numerous  observations 
seem  to  show  the  possibility  of  its  occurrence  physiologically  (see,  in 
regard  to  the  placenta,  Lectm*e  XLII.)  and  in  inflammatory  and  tu- 
mor new  formations.  In  these  changes  there  are  always  large  cells, 
protoplasm  masses  of  various  natures,  in  which  at  first  are  formed 
small  cells,  recognizable  by  their  coloring  with  hsemoglobine,  which 
gradually  acquii'e  the  size   and  color  of  red  blood-cor2)uscle!>,  and 


ANGIOMATA.  713 

finally,  surrounded  by  a  fibrinous  liquid,  lie  in  a  cavity  composed 
of  cells.  It  is  probable  that  these  cavities  later  become  true  vessels, 
or  that  at  least  a  communication  with  previously  formed  vessels  de- 
velops. 

My  investigations  of  cavernous  lymphangiomata  support  the 
idea  that  in  the  immediate  vicinity  of  the  vessels,  possibly  in  their 
walls,  cells  collect,  soften  in  the  middle,  and  then  communicate  with 
the  interior  of  the  vessel  ;  w^e  shall  hereafter  find  a  similar  process 
in  villous  sarcoma.  That  the  framework  of  cavernous  tumors,  at 
least  sometimes,  develops  independently  of  the  vascular  system,  is 
shown  by  the  occurrence  of  small  tumors,  of  cavernous  formation, 
but  not  yet  filled  with  blood,  in  the  liver  along  with  nimierous 
similar  tumors  fully  developed  and  communicating  with  the  ves- 
sels. 

Another  method  of  treatment  of  angioma,  in  addition  to  those 
mentioned  on  page  711,  is  one  spoken  of  for  lupus,  by  making 
numerous  fine  parallel  incisions  through  the  skin  by  which  many 
vessels  are  divided  and  subsequently  atrophy. 

Instead  of  using  silk  to  ligate  angiomatous  tumors  we  may  here 
also  apply  elastic  ligatures.  If  the  mark  is  flat  and  wide-spread, 
the  incisions  may  first  be  tried,  and  after  part  of  the  vessels  have 
ati'ophied,  fuming  nitric  acid  may  be  applied  to  the  remainder  of 
the  tumor. 

About  1870  the  translator  treated  one  of  these  tumors,  affect- 
ing the  lobe  of  the  left  ear  and  extending  to  the  cheek,  by  the  gal- 
vano-cautery.  Two  applications  made  at  intervals  of  a  fortnight 
caused  its  entire  disappearance,  only  a  slight  scar  being  left.  As  a 
warning  to  others  using  the  cautery  about  the  face  while  the  patient 
is  etherized,  it  may  be  added  that  in  spite  of  the  ether  having  been 
carefully  wiped  away  before  the  cautery  was  heated,  on  approach- 
ing it  to  the  face  the  fumes  of  the  ether  expired  by  the  patient  at 
once  took  fire  ;  after  extinguishing  the  flame  a  paper  was  held  be- 
tween the  mouth  and  ear  to  keep  away  the  fumes  while  the  opera- 
tion was  being  completed.] 


In  the  form  of  an  appendix  I  may  also  mention  : 
1.  Cavernous  hjinphatie  tumors  (lymphangioma  cavcrnosura),  a 
very  rare  form  of  neoplasm,  which  is  of  the  same  anatomical  for- 
mation as  cavernous  blood-tumors,  but  with  the  difference  that,  in- 
stead of  blood,  there  is  lymph  in  the  mesh-work.  This  variety  of 
the  tumor  occurs  congenitally  in  the  tongue  as  a  form  of  macroglos- 


714 


SARCOMATA. 


sia  (there  is  also  a  fibrous  form)  ;  in  young  persons  it  sometimes  or*- 
curs  at  diiferent  parts  of  the  subcutaneous  cellular  tissue  (lips,  cheeks, 
chin,  thigh). 

2.  JVcevus  vasoulosus,  the  so-called  fire-mole;  this  is  a  plexiform 
ano-ioma  of  the  most  superficial  cutaneous  vessels,  which  ceases  to 
grow  from  the  moment  of  birth.  There  is  no  other  difi"erence  be- 
tween fii"e-mole  and  growing  angioma.  I  have  already  said  that  there 
are  various  combinations  of  hypertrophy  of  the  skin,  pigmentation, 
ectasia  of  the  vessels,  and  formation  of  hair  in  these  congenital  marks. 
If  these  marks  be  on  the  face,  and  not  too  large  (sometimes  they  im- 
plicate half  the  face),  we  may  extirpate  them  partly  or  entirely,  and 
subsequently  make  a  plastic  operation,  or  we  may  resort  to  cauteriza- 
tion. Some  of  these  marks,  where  only  the  tops  of  the  papillre  are 
afi"ected,  may  be  greatly  improved  or  even  cured  by  a  very  superficial 
peeling  of  the  skin. 

LECTURE    XLVIII. 

8.  Sarcomata. — Anatomy :  a,  Granulation  Sarcoma ;  5,  Spindle-celled  Sarcoma ;  c,  Giant- 
celled  Sarcoma ;  d,  Stellate  Sarcoma ;  «,  Alveolar  Sarcoma ;  /,  Pigmented  Sarcoma. 
— Clinical  Appearance. — Diagnosis. — Course. — Prognosis. — Mode  of  Infection. — 
Topography. — Central  Osteosarcoma. — Periosteal  Sarcoma. — Sarcoma  of  tlie  Mam- 
ma, of  the  Salivary  Glands. — 9.  Lymphomata. — Anatomy. — Relations  to  Leucicmia. 
— Treatment. 

8.  SARCOMATA. 

Over  no  group  of  tumors  has  there  so  long  been  uncertainty 
about  their  anatomical  position  and  extent  as  about  sarcoma.  The 
old  name,  taken  from  (rap^,  flesh,  merely  meant  that  on  section  the 
tumor  had  a  fleshy  look ;  of  course,  this  did  not  make  a  diagnosis, 
as  it  was  greatly  a  matter  of  choice  what  should  be  called  flesh. 
The  attempt  to  employ  the  name  "sarcoma"  solely  for  tumors  com- 
posed of  muscle  filaments  {Schu/i),  that  is,  to  identify  it  with  those 
tumors  now  called  "  myoma,"  was  not  popular.  Subsequently  the 
term  became  somewhat  more  definite,  as  it  was  made  to  include  all 
tumors  rich  in  cells  which  had  no  decided  alveolar  formation,  and  were 
not  carcinomatous.  It  is  only  for  the  last  ten  years  that  the  follow- 
ing histological  definition  has  received  general  acceptance  and  has 
become  quite  common.  A  sarcoma  is  a  tumor  consisting  of  tissue  be- 
longing to  the  developmental  series  of  connective-tissue  substances 
(connective  tissue,  cartilage,  bone),  muscles,  and  nerves,  which,  as  a 
rule,  does  not  go  on  to  the  formation  of  a  perfect  tissue,  but  to  pecu- 
liar degenerations  of  the  developmental  forms.  Some  pathologists 
•vould  gladly  see  "muscles  and  nerves"  excluded  from  this  definition, 
but  when  speaking  of  spindle-celled  sarcoma  I  shall  show  why  I  can- 


TUMORS. 


715 


not  admit  this.  If  it  is  desired  to  term  the  inflammatory  neoplasias  m 
their  various  stages  examples  of  sarcoma  {Rindfleiscli)^  I  assent  tc 
it,  as  this  definition  would  agree  pretty  well  with  mine-. 

After  this  anatomical  basis  was  found  for  "  sarcoma,"  it  soon  ap- 
peared that  it  could  be  diagnosed,  even  with  the  naked  eye,  and  that 
clinically  also  something  could  be  said  about  the  peculiar  course  of 
these  tumors.  As  I  think  that  the  subdivisions,  according  to  histo- 
logical peculiarities,  are  less  important  for  the  diagnosis  of  these  tu- 
mors during  life,  and  that  their  diagnosis,  prognosis,  and  course,  de- 
pend so  much  on  their  point  of  origin,  the  rapidity  of  their  growth, 
etc.,  I  prefer  hereafter  classing  together  the  clinical  remarks  on  sar- 
coma, and  here  merely  considering  more  attentively  the  histology. 
We  shall  divide  sarcoma  into  the  following  forms  : 

FiQ.  1.30.  {a.)    Granulation  sarcoma^  round-celled  sar- 

f'^K^'^'S^^  coma  of  Virchow.     This  tissue  is  the  same,  or 

^^<jjSf^^       very  like  that  of  the  upper  layer  of  granulations  ; 
K^^^^^^^^^^V   ^*  always  contains   chiefly  small  round   cells,  like 
^^^  ^^1^^"%^  b'^P^^'^sll^  5  ^^'^  intercellular  substance  is  some- 
^^^ v^^^^^^^Y  times  scarcely  perceptible,  again  it  is  in  greater 
N<4^1^#^^^  quantities,  and  may  be  perfectly  homogeneous,  as 
"^A^^     in  neuroglia  (  Virchoio's  glioma  and  glio-sarcoma), 
Tissue  of  a  graTiuiation  ^j.  j^  is  slightly  striated  (Fig.  130),  Or  even  fibrous, 

earcoma.  Mayuifled  350  t>       j  V      to  /}  » 

diameters.  Or  may  be  oedematous  (as  in  large  mammary  sar- 

comata). Lastly,  it  may  also  be  reticulate,  and  so  approximate  the  tis- 
Bue  of  lipoma. 


Fig.  131. 


Tissue  of  a  ulio-sarcoma  after  Virchow.    Miisnified  350  diameters. 

(b.)  Spindle-celled  sarcoma  is  composed  of  closely-packed,  usually 
thin,  elongated  spindle-cells,  so-called  filament-cells.     Usually  there 


■716 


SARCOMATA. 


Fig.  132. 


is  no  intercellular  substance,  occasionally  there  is  some  ,  it  may  be 
homogeneous  and  soft,  or  fibrous  ;  if  the  fibrous  portion  preponderates, 
tlie  tumor  is  called  fibro-sarcoma, 
or  fibroma.  Formerly  this  spindle- 
celled  tissue  was  termed  young 
connective  tissue  (tissue  fibroplas- 
tique,  Lebert) ;  but  from  my  histo- 
genetic  investigations  in  the  em- 
bryo I  have  long  protested  against 
this  view,  for  spindle-celled  tissue, 
as  we  usually  find  it  in  these  sar- 
comata, does  not  occur  in  embryonal 
tissue  at  any  period,  not  even  in  the 
tendons ;  the  physiological  exam- 
ple of  this  tissue  is  young  muscle 
and  nerve  tissue ;  these  spindle- 
celled  sarcomata  would  then  be 
young  myomata  or  neuromata. 
Virchow  has  carried  the  same 
view  further,  especially  as  far  as 
regards  fil)rous  uterine  tumors  (page 
685).  I  protested  against  this 
view  of  Vlrchow's,  with  its  con- 
sequences, as  the  diagnosis  is  always  doubtful  in  special  cases. 
When  a  nerve  contains  a  tumor  consisting  of  elongated  spindle- 
cells,  whose  ends  terminate  in  fine  filaments,  it  is  very  natural  to  re- 
gard it  as  a  neuroma  whose  elements  are  not  fully  developed  at  any 
point.  VVIien  a  spindle-celled  tumor  is  developed  in  muscle,  and  the 
fibre-cells  show  band-like  forms,  even  fine  granulation,  as  in  the  com- 
mencement of  striation,  there  could  be  no  blame  for  calling  these  tu- 
mors "  myomata,"  under  the  idea  that  they  were  young  muscle-tissue 
that  had  not  gone  beyond  certain  bounds  of  development.  So  far 
there  is  no  objection  to  this  view.  But  when  a  spindle-ceUed  sarcoma 
comes  in  the  cutis,  or  on  the  penis  (where  I  recently  saw  a  remark- 
able case),  we  may  be  very  doubtful  whether  the  case  is  one  of  young 
neuroma,  myoma,  or  fibroma  ;  in  both  of  these  parts  there  are  nerves, 
muscles,  and  connective  tissue.  If,  then,  there  be  nothing  typical  in 
the  arrangement  or  form  of  the  cells,  and  the  histological  mode  of 
origin  cannot  be  certainly  determined,  we  must  content  ourselves  witli 
the  term  "  spindle-celled  sarcoma."  At  all  events,  we  have  to  deal 
with  a  fibrous  tissue,  whose  development  has  not  advanced  beyond 
the  production  of  spindle-cells.  Moreover,  I  tliink  I  can  afBrra  from 
my  observations  that  the  course  and  prognosis  of  these  tumors  scarcel_y 


Tissue  of  a  spindle-celled  sarcoma. 


TUMORS. 


71V 


Fig.  183. 


depend  on  their  origin,  but  far  more   on  their  locality,  rapidity  of 
growth,  consistence,  and  other  clinical  conditions. 

(c.)  Giant-celled  sarcoma  is  a 
name  given  by  Virchow  to  a  variety 
of  sarcoma  containing  very  large 
cells,  which  are  partly  round,  partly 
polymorphous,  and  supplied  with 
many  offshoots  (Fig.  133).  These 
cells,  which  normally  occur  in  the 
medulla  of  the  bones  of  the  fostus, 
although  not  so  large  as  in  tumors, 
have  excited  great  astonishment  by 
their  size ;  they  are  the  largest  un- 
formed protoplasm  collections  that 
have  been  seen  in  man ;  they  may 
contain  thirty  or  more  nuclei,  and 
their  origin  from  a  simple  cell  by  a  series  of  transformations  is  gen- 
erally easily  followed.  These  giant-cells  occur  in  spindle-celled,  as 
well  as  in  fibro-sarcoma ;  they  occur  somewhat  smaller  sporadically, 
and  are  also  found  in  granulation  and  myxosarcomata.    They  are  most 


V 


Giant-cell?  from  a  parcoma  of  the  lower 
jaw.    Magnified  350  diameters. 


PiQ.  134. 


.€-  ^'7 


V 


^ 


-f- 


Giant-celled  sarcoma  witb  cysts  and  ospifyincr  foci  from  the  lower  jaw.    Magnified  360 

diameters. 


frequent  in  the  central,  less  so  in  periosteal  sarcoma,  but  I  have  seen 
them  even  in  muscle-sarcoma.     Bv  their  size  they  occasionally  give 


718 


SARCOMATA. 


Fig.  135. 


the  tissue  an  apparently  alveolar  (Fig.  134)  structure,  and  bj  soften- 
ing may  lead  to  formation  of  cysts  (a),  or  may  ossify  (i). 

A  peculiar  formation  from  sarcoma,  which  is  allied  to  the  giant- 
cell,  although  never  growing  very  large,  may  be  mentioned  here.  In 
a  granulation-sarcoma  of  the  dura  mater,  which  ac- 
cidentally fell  into  my  hands,  there  were  great  num- 
bers of  globular,  multinucleated  cells,  which  were 
surrounded  with  a  membrane-like  connected  layer  of 
spindle-cells  (Fig.  135).  I  hazard  no  explanation  of 
these  elements,  but  suspect  that  they  are  associated 
with  the  formation  of  tufts  on  the  cerebral  mem- 
branes, and  with  tufted  fibro-sarcomata,  which  Vir- 
chow  calls  brain-sand  tumors  (psammone),  when  they 
contain  brain-sand.  Possibly,  these  peculiar  forma- 
tions are  aborted  excrescences  from  blood-vessels,  an 
idea  I  have  long  cherished,  and  which  is  apparently 
confirmed  by  a  recently-published  observation  of 
Arndt,Virho  saw  these  spheres  attached  to  vessels  by 
pedicles.  Waldeyer  lately  showed  that  these  and 
allied  formations,  which  occur  especially  in  intracranial  tumors)  start 
from  the  perithelial  (adventitial)  cells  of  cerebral  vessels.  The  neo- 
plasiae  belonging  here,  but  not  yet  sufficiently  analyzed  and  classified, 


Cell-jilobulcs  from  a 
earcoma  of  the  dura 
mater.  Matjuifiecl 
350  diameters. 


riG.  186. 


Fig.  137. 


Mucous  tissue  from  a  myxosarcoma  of  the 
scalp.    Magnified  400. 


Mucous  tissue  from  an  adenomyxoma 
of  the  mamma.    Ma^'uified  400. 


TUMORS. 


719 


as  well  as  the  alveolar  sarcomata  of  which  we  shall  soon  treat,  often 
so  much  resemble  carcinomata  in  their  structure  that  they  are  very 
difficult  to  distinguish.  According  to  recent  observations,  especially 
those  of  Sattler,  what  I  formerly  described  as  cylindroma,  and  erro- 
neously classed  with  adenoma,  also  belongs  in  this  class. 

{cl)  Net-celled  sarcoma.  Mucous  sarcoma.  (Gelatinous  sarcoma 
of  MoJdta7isky.)  For  the  offshoots  from  cells  to  develop  well  and  be 
distinctly  seen,  there  must  be  considerable  soft  intercellular  substance 
present.  Hence  sarcomata  with  gelatinous  mucous  intercellular  sub- 
stance, which  contain  any  stellate  cells,  are  the  most  beautiful.  But 
this  is  not  always  the  case.  There  are  also  granulation-sarcomata, 
that  have  a  claim  to  be  regarded  as  mucous  or  gelatinous  tumors. 
If  we  should  wish  to  class  the  tumors  from  the  above  groups,  when 
they  appear  gelatinous,  together  because  they  contain  much  mucous 
(fiv^a),  we  may  call  them  mysomata  (Virchow),  or  retain  their  old 
name,  collonema  {J.  Mailer).  Virchow'^s  true  mucous  tissue  (Fig. 
135)  undoubtedly  belongs  to  the  developmental  series  of  the  connec- 
tive tissues  ;  occasionally  it  also  occurs  in  mucous  granulations.  But 
frequently  also  we  find  spindle-cells  and  round  cells  in  myxoma,  and, 
if  there  be  at  the  same  time  any  developed  cartilage,  the  mucous  tis- 
sue may  be  regarded  as  young  or  softened  cartilage-tissue,  which  be- 
comes the  more  probable  if  a  myoxoma  contains  honey-comb-like 
septa  such  as  are  found  in  chondroma.  We  may  use  the  terms 
myxosarcoma,  myxochondroma,  etc. 

(e.)  Alveolar  sarcoma.  This  rare  form  of  tumor  (occuiring  in  the 
cutis,  muscle,  and  bone)  is  very  difficult  to  characterize  anatomically ; 
from  the  size  and  arrangement  of  its  cells,  it  may  in  spots  so  much 
resemble  carcinoma,  that  I  would  not  trust  myself  to  decide  correctly 
on  every  piece  of  such  a  tumor  placed  under  the  microscope.  The 
cells  of  these  elements  are  much  larger  than  lymph-cells,  about  the 
size  of  cartilage-cells,  or  of  moderately  large  flat  epithelium,  and 
usually  have  one  or  more  large  nuclei,  with  glistening  nucleoli.  The 
cells  are  embedded  in  a  fibrous,  or  more  rarely  homogeneous,  slightly- 
developed  intercellular  substance  of  exquisite  alveolar  type,  in  such  a 
way  that  they  lie  together  separately,  or  more  rarely  in  groups  (Figs. 
138  and  139).  They  are  most  intimately  connected  with  the  fibres, 
and  are  difficult  to  detach  from  the  fibrous  mass.  The  latter  two  pe- 
culiarities are  important  for  the  histological  diagnosis  of  "  sarcoma," 
for  they  show  the  large  cells  are  connective-tissue  cells,  not  epithelial 
sells,  as  in  true  carcinoma-tissue.  Occasionally  the  cellular  elements 
of  these  sarcomata  lie  in  immediate  contact,  without  any  intercellular 
substance;  the  resemblance  to  epithelial  carcinoma  may  prove  de- 
oeptive.  Virchow  has  described  and  deduced  this  form  from  soft 
warts  of  the  cutis. 


720 


SARCOMATA. 


Fie.  13b. 


Fig.  130. 


i^ 


r 


Alveolar  sarcoma  from  tne  deltoid  mnscle. 
Maimifli-d  400  diameters. 


MajjuiiirJ  Iju  diULUftir^T. 


(y.)  Pigmentary  sarcoma.  Melanotic  sarcoma.  Melanoma.  All 
these  names  indicate  pigment  formation  in  sarcoma.  Tliis  pigment, 
which  is  usuall}'  granuUir,  rarely  diffuse,  is  brown  or  black,  lies  almost 
always  in  the  cells,  rarely  in  the  intercellular  substance.  Part  or  the 
whole  of  the  tumor  may  be  faintly  or  distinctly  black.  Any  of  the 
above  forms  of  sarcoma  may  occasionally  be  pigmented,  but  I  have 
most  frequently  found  this  to  be  the  case  in  the  last  form,  and  in  the 
spindle-celled  sarcoma.  Melanomata  develop  most  frequently  in  the 
cutis,  especially  of  the  foot  and  hand,  but  also  on  the  head,  neck,  and 
trunk. 

The  arrangement  of  the  cellular  elements  in  sarcoma  depends,  on 
the  one  hand,  on  certain  directions  of  the  fibres  or  fibre-cells  in  the 
tissue  of  the  tumor ;  on  the  other,  on  the  form  of  the  vascular  net- 
work ;  from  these  circumstances,  as  well  as  from  the  development  of 
giant-cells,  or  similar  formations,  there  may  result  an  arrangement  of 
the  tissue  of  the  tumor,  scarcely  distinguishable  from  the  areolar 
formation  formerly  ascribed  exclusively  to  carcinoma-tissue.  Thi.s 
should  not  astonish  3'ou,  for  in  cartilage  also  Ave  have  a  tj'pe  of  cavi- 
ties with  enclosed  cells,  and  also  the  net-work  of  the  lymphatic  glands, 
which  undoubtedly  belong  to  the  system  of  connective-tissue  sub- 
stances, but  must  also  be  termed  alveolar  formations. 


TUMORS.  721 

[To  return  a  moment  to  (c?)  :  the  large  cells  found  normally 
in  the  medulla  of  fetal  bones  were  termed  by  Rohin  "  myelo- 
plaxes,"  and  giant-cells,  from  their  resemblance  to  these,  have  occa- 
sionally received  the  same  name.  Giant-cells  are  often  closely  re- 
lated to  the  formation  of  vessels,  in  whose  vicinity  they  usually  lie, 
as  round  cells,  derived  from  normal  connective  tissue,  whose  pro- 
toplasm increases,  probably  at  the  expense  of  neighboring  cells,  and 
the  nuclei  multiply.  In  this  phase  of  development  they  are  true 
hgematoblasts  ;  i.  e.,  the  pi'otoplasm  partly  changes  to  htemoglobine, 
which  divides  up  into  red  blood- corpuscles.  The  intercellular  sub- 
stance near  the  giant-cells  becoming  fluid,  may  form  cavities  con- 
taining blood-corpuscles  (blood-cysts).  Although  giant-cells  are 
not  confined  to  the  above  tumors,  but  occur  in  spindle  and  round- 
celled  sarcoma,  yet  here  they  are  so  numerous  and  large  that  a 
variety  of  sarcoma  has  been  named  from  them.] 

The  following  forms  of  sarcoma  ai'e  of  developed  connective 
tissue,  whose  form  depends  greatly  on  the  vessels  : 

(^.)  The  (infiltrated  and  superficial)  villous  sarcoma,  pearl-iu- 
mors,  and  2}sa>}imona.  As  is  well  known,  the  serous  membranes 
have  the  peculiarity  in  some  pathological  processes  of  forming 
ragged  proliferations,  whose  basis  is  connective  tissue  and  ulti- 
mately vessels,  and  whose  covering  consists  of  multiplied  and 
enlarged  endothelial  cells.  Well-developed  shreds  of  synovial 
membrane  in  arthritis  deformans,  shreddy  proliferations  of  the 
pericardium  and  endocardium  on  the  valves,  the  plexus  choroidei, 
and  the  Pacchionian  granulations  of  the  cerebral  membranes,  are 
the  types  of  this  neoplasia.  The  tumors  which  to  a  certain  extent 
may  be  regarded  as  the  highest  stages  of  development  of  this 
variety  are  only  found  in  the  membranes  of  the  brain  or  the  nerve- 
sheaths  directly  proceeding  from  it  ;  some  of  these  neoplasise  have 
a  villous  character,  at  least  exteriorly  ;  others  form  compact  masses, 
the  dendritic  tissues  growing  through  each  other. 

These  tumors  form  thus  :  A  circumscribed  cellular  infiltration 
{a,  Fig.  139  a)  begins  in  the  adventitious  sheath  of  the  vessel, 
which  gives  rise  to  clubbed,  shreddy  outgrowths,  which  soon  be- 
come hyaline  or  filamentary  connective  tissue,  and  then  develop  a 
cavity  in  them,  which  gradually  unites  with  the  caliber  of  the  ves- 
sel (b).  Part  of  the  cells  assume  epithelial  forms  and  envelop  the 
above  club-shaped  neoplasise  (c).  Between  these  cell-masses  we 
find  spheres  of  flat  compressed  cells  (e),  which  in  part  become  dry 
and  under  some  conditions  even  calcareous.  Whether  the  pearl- 
tumors  (  Virchou')  starting  from  the  cerebral  membranes,  which 
are  composed  of  pearly  non-vascular  nodules  from  the  size  of  a 
47 


722 


TUMORS. 


millet-seed  to  a  pea,  are  composed  of  such  endothelial  spheres,  or 
are  true  epithelial  formations,  I  shall  not  attempt  to  decide,  as  I 
have  made  no  personal  observations,  and  there  has  been  nothing 
published  on  this  point  recently.  According  to  Yirchoic's  investi- 
gations, the  pearls  of  the  intracranial  tumors  are  comj^osed  of  con- 


Fio.  139  A. 


From  a  villous  sarcoma  fcancroid  of  Arndf)  of  tho  pia  mater  a,  Commencing  ccll-infiltralion 
in  the  capillary  walls;  6,  clubbed  proliferations  fjrowing  from  the  walls  of  the  vessels  ; 
c,  the  game  covered  witli  a  thick  layer  of  endothelium  ;  (/,  eudothelial  cells  of  the  highest 
development,  not  to  be  distinEruished  from  epithelial  cells;  e,  conglomeration  of  these 
cells  into  a  spherical  shape.    Endothelial  pearls.    Magnified  400. 

nective-tissue  cells  ;  hence  they  should  be  classed  with  sarcomat.i. 
Thymus  pearls  are  the  physiological  examples  of  this  form,  which 
from  their  non-vascularity  also  have  an  analogy  to  tubercle. 

Another  tumor  described  by  Virchoio  and  renamed  belongs  here, 
the  2^sammona.  This  also  has  only  been  observed  in  the  brain  or 
in  the  orbit,  and  is  related  to  the  villous  and  to  plexiform  sarcoma, 


SARCOMATA. 


723 


which  we  shall  soon  describe.  This  variety  of  tumor  is  character- 
ized by  the  occurrence  of  calcareous  spheres,  having  the  form  of 
the  concrements  which  are  found  in  the  pineal  gland,  and  are  there 
known  as  brain-sand  {Tzoaiindg,  sand).  Like  the  thymus  pearls,  these 
are  mostly  connected  with  the  vessels,  and  are  probably  mostly  cal- 
cified endothelial  pearls  ;  but  Virchow  says  that  direct  calcification 
of  connective  tissue  may  lead  to  the  same  forms. 


Psammona,  after  Virchow.    Magnified  about  200. 

(A.)  Plexiform  (cancroid,  adenoid)  sarcoma.  This  form  of  sar- 
coma also  is  chiefly  found  in  the  orbit  and  brain,  but  sometimes 
occurs  in  the  parotid  gland.  It  can  only  be  distinguished  by  very 
careful  examination  from  some  forms  of  carcinoma  to  be  hereafter 
described.  Plexiform  cylinders,  clubs,  and  spheres  of  small  cells 
spread  out  in  the  connective  tissue,  separating  its  bundles  and  fill- 
ing all  the  interspaces  between  them,  in  doing  which  they  naturally 
push  into  the  lymphatic  vessels  and  perivascular  lymphatic  spaces. 
It  cannot  always  be  determined  whether  the  cells  first  increasing 
are  wandering  cells,  connective-tissue  cells,  or  cells  from  the  Avails 
of  the  vessels,  endothelium,  or  perithelium  ;  perhaps  they  all  par- 
ticipate at  the  same  time  or  after  one  another. 

[Development  of  the  tumor  starts  from  the  blood-vessels,  which, 


724 


TUMORS. 


by  proliferation  of  their  endothelium,  become  tubular,  netlike, 
anastomosing  structures,  full  of  small,  round,  or  irregular  cells, 
embedded  in  a  close,  fibrillar  connective  tissue.  The  cells  enlarge, 
their  borders  become  indistinct,  finally  they  so  fill  the  tube  that  its 
caliber  is  no  longer  perceptible  ;  the  nuclei  of  the  cells  originating 
from  the  endothelium  remain,  and  distinguish  the  tubuli  from  true 
epithelial  gland-tubes.  While  the  endothelium  has  increased  in 
size,  the  rest  of  the  vascular  wall  has  become  hyaline,  so  that  in  the 
tubes  there  is  a  wall  (tunica  propria)  and  a  distinct  inner  coating 
of  cells.  At  some  places  occur  irregular,  nodular,  villous  forma- 
tions, with  thick  hyaline  walls  and  cellular  contents.  Elsewhere 
from  the  hyaline  sheath  papillary  offshoots  project  among  the  cells, 


Fig.  139  c. 


a,  From  a  cerebral  tumor,  after  Arnold,    h.  From  a  cerebral  tumor,  after  Bindfleisch.    Magni- 
fied 300-100. 

and,  in  sections,  these  appear  as  hyaline  spheres,  surrounded  on  all 
sides  by  cells.  The  enveloping  cells  have  such  an  exact  epithelial 
form  as  to  be  mistaken  for  gland-tissue,  especially  if  not  highly 
magnified.  From  the  prominent  participation  of  the  vessels  in  the 
formation  of-  such  sarcomata,  this  group  of  tumors  has  been  called 
"angiosarcoma"  (h,  Fig.  1.S9  c).  These  are  not  to  be  confounded 
with  cavernous,  telangiectatic  sarcoma,  which  are  characterized  by 
very  great  vascularity. 

The  hyaline  metamorphosis  sometimes  affects  also  the  cells  in 
the  tubes  ;  it  starts  from  the  nuclei,  and,  by  transformation  of  the 
protoplasm,  branched,  cactus-like,  hyaline  formations  are  thus  de- 
veloped. As  the  degeneration  begins  in  the  center,  the  hyaline 
cylinders  are  often  found  enveloped  in  cells.     The  same  process  is 


SARCOMATA. 


725 


witnessed  in  cell-groups  formed  by  proliferation  of  connective-tis- 
sue elements.  These  peculiar  hyaline  nodules  and  cylinders  (Figs. 
139  D,  139  e)  were  at  first  regarded  as  lymphatic  vessels  ;  then  it 


Fig.  139  d. 


Commencing  hyaline  metamorphoses  in  the  early  stasres  of  a  plexiform  sarcoma.    Commence- 
ment of  the  formation  of  cylindroma.    After  SatUer.    Ma^iiilied  509. 

vras  thought  the  cell-tubes  contained  gland-elements.  From  the 
hyaline  cylinders  the  tumors  were  called  "  cylindroma."  Sattler's 
investigations  first  fully  explained  the  development  of  these  tumors. 

Fig.  139  e. 


From  a  cylindroma  (plexiform  sarcoma  with  hyaline  vegetations)  of  the  orbit.    Magnified  300. 

All  observations  seem  to  show  that  the  hyaline  degeneration  is 
only  an  accident  occurring  in  certain  varieties  of  plexiform  or  angio- 
sarcomata.] 


726  TUMORS. 

Coming  now  to  the  symptoms  of  sarcoma  perceptible  to  the  naked 
eye,  we  must  first  state  that  in  most  cases  these  neoplasias  have  a 
roundish,  sharply-bounded  form,  indeed,  are  usually  distinctly  encap- 
sulated ;  this  is  a  very  important  distinguishing  mark  from  infiltrated 
carcinoma.  Sarcoma  very  rarely  appears  on  surfaces  (whether  free  or 
sac-like  membranes)  in  a  papillary  or  poljrpous  form ;  still,  there  are 
non-glandular  nasal  and  uterine  polypi,  also  soft  warts  on  the  skin 
and  mucous  membrane,  which,  from  their  histological  structure,  can 
only  be  classed  among  the  sarcomata.  The  consistence  and  color  of 
sarcomata  vary  so  much  that  nothing  general  can  be  said  about 
tliem  ;  they  may  be  as  hard  as  cartilage,  or  of  gelatinous,  nearly  fluid 
consistence.  On  incision,  the  tumor  may  appear  bright  red,  white, 
yellowish,  brown,  gray,  black,  dark  red,  and  difi'erent  shades  of  all 
these  colors  may  appear  on  the  same  cut  surface,  apart  from  the  pig- 
mentation ;  this  depends  especially  on  their  vascularity,  and  on  more 
or  less  recent  extravasations  of  blood  in  the  tumor.  The  vascularity 
varies  greatly ;  sometimes  there  is  only  a  scanty  net-work  of  vessels ; 
again,  the  tumor  is  like  a  sponge,  traversed  by  cavernous  veins.  We 
must  here  mention  another  peculiarity  of  sarcoma :  it  is  occasionally 
so  white  that,  if  it  be  soft  at  the  same  time,  it  greatly  resembles 
brain-matter.  This  medullary  sarcoma  (encephaloid)  usually  has  all 
the  malignant  qualities  of  sarcoma  in  the  highest  grade,  and  is  much 
feared ;  it  may  have  any  of  the  above-described  histological  charac- 
ters. Tumors  which  may  be  torn  up  into  bundles  in  certain  directions 
have  been  called  sarcoma  fasciculatum  (formerly  carcinoma  fascicu- 
.  latum).  The  anatomical  metamorphoses  that  take  place  in  sarcoma 
are  various :  the  different  modes  of  softening  predominate ;  mucous 
softening,  even  to  the  formation  of  mucous  cysts,  fatty  and  cheesy 
degenerations,  are  frequent.  Ossification  is  very  common  in  sarco- 
mata connected  with  bone,  and  may  go  on  until  the  whole  tumor  is 
more  or  less  completely  transformed  to  bone.  Cicatricial  shrinkage 
scarcely  ever  occurs  in  sarcoma  ;  this  is  another  important  difference 
from  carcinoma.  Ulceration  from  within  outward,  opening  out  hke  a 
crater,  is  rare ;  sarcomata  of  the  cutis  ulcerate  early,  without,  however, 
causing  extensive  destruction ;  ulceration  of  hard  sarcomata  occasion- 
ally produces  well-developed  granulations. 

The  diagnosis  of  sarcoma  during  life  is  made  by  attending  to  the 
following  points:  Sarcomata  develop  with  peculiar  frequency  after 
precedent  local  irritations,  especially  after  injuries ;  cicatrices,  also, 
are  not  unfrequently  the  seat  of  these  tumors  ;  black  sarcomata  may 
come  from  irritated  moles.  Skin,  muscles,  nerves,  bone,  periosteum, 
and,  more  rarely,  glands  (among  these  the  mamma  most  frequently), 
are  the  seats  of  these  tumors.     Sarcomata  are  rarest  in  children,  rare 


SARCOMATA.  727 

between  ten  and  twenty  years,  most  frequent  in  middle  life,  and  rarer 
again  in  old  age.  According  to  my  observation,  men  and  women  are 
affected  with  equal  frequency.  If  these  tumors  be  not  located  in 
or  on  nerve-trunks,  they  are  usually  painless  till  they  break  out.  If 
the  sarcoma  be  in  the  subcutaneous  cellvilar  tissue  or  in  the  breast,  it 
may  be  felt  as  an  encapsulated  movable  tumor.  The  growth  is  some- 
times rapid,  sometimes  slow ;  the  consistence  varies,  so  that  it  can 
scarcely  be  used  as  a  point  in  diagnosis. 

Course  and  prognosis.  A  sarcoma  may  develop  solitarily,  may 
remain  so,  and  never  return  after  operation.  It  may  develop  as  soli- 
tary or  multiple,  and  return  after  repeated  extirpation ;  metastatic 
tumors  may  form  in  the  lungs  or  liver,  and  thus  this  disease  may  cause 
death  in  three  months.  You  see  that  the  greatest  benignity  and 
greatest  malignity  may  be  united  in  this  one  group  of  neoplasia  ;  in- 
deed, I  can  assure  you  that  two  sarcomata  of  the  most  similar  histo- 
logical qualities  (usually,  however,  with  different  consistence)  may 
differ  entirely  in  course.  From  this  circumstance  the  greatest  objec- 
tions have  been  made  to  pathological  histology ;  it  must  be  acknowl- 
edged that  the  histological  structure  of  a  tumor  by  no  means  corre- 
sponds to  its  clinical  course ;  but  for  this  reason  to  cast  a  slur  on 
anatomy  would  be  just  as  strange  as  to  blame  it  because  we  cannot 
certainly  distinguish  between  the  microscopic  preparations  of  a  sali- 
vary, lachrymal,  or  mucous  gland,  although  they  play  very  different 
parts  in  the  organism.  We  must  first  overcome  the  habit  of  seeking 
specific  anatomical  forms  for  specific  functions.  But  there  is  no  lack 
of  indications  for  prognosis  in  regard  to  any  sarcoma.  We  shall 
hereafter  speak  of  the  importance  in  this  respect  of  the  location  of 
the  tumor;  the  consistence  is  important,  firm  sarcomata  are  of  better 
prognosis  than  soft  ones ;  alveolar  forms  are  of  especially  bad  prognosis, 
and  still  more  so  are  the  soft  granulation  and  spindle-celled  sarcomata, 
which  usuall}^  appear  in  the  medullary  form  ;  black  sarcomata  are  also 
especially  dangerous,  the  firm  ones  being  less  rapid  in  theu-  course  than 
the  soft.  The  rapidity  of  the  growth  first  appearing  is  very  impor- 
tant for  the  prognosis ;  this  is,  moreover,  in  proportion  to  the  consist- 
ence ;  if  a  sarcoma  has  taken  four  or  five  years  to  attain  the  size  of  a 
hen's  e^g,  the  prognosis  is  not  so  bad ;  if  in  four  or  five  weeks  it  has 
grown  to  the  size  of  a  fist,  it  is  very  bad.  A  sarcoma  may  be  mis- 
taken for  a  cold  abscess ;  I  know  of  one  case  where  a  sarcoma  of  the 
abdominal  w^alls  developed  so  rapidly  that  at  first  it  was  diagnosed  to 
be  furuncle.  In  a  few  months  the  patient  was  covered  with  sarco 
mata,  and,  in  less  than  three  months  from  the  development  of  the  first 
tumor,  she  died  from  the  disease  attacking  the  lungs.  Sometimes, 
however,  a  slowly-giowing,  firm  sarcoiiia   is  followed  by  one  of  rapid 


728  TUMORS. 

growth,  but  the  reverse  of  this  never  occurs.  Usually,  sarcomata 
develop  in  strong,  well-nourished,  often  in  particularly  healthy  and  fat 
persons ;  I  saw  a  medullary  sarcoma  of  the  mamma  in  a  blooming, 
strong,  healthy  girl  eighteen  years  old ;  she  died  of  sarcoma  of  the 
lungs  a  few  months  after  operation.  The  mode  of  development  of 
sarcomata  which  appear  successively  is  very  characteristic.  The  first 
tumor  is  completely  extirpated ;  after  a  time,  in,  under,  or  near  the 
cicatrix,  a  new  tumor  appears ;  this  also  is  completely  removed ;  again, 
a  new  tumor  appears  at  the  point  of  operation,  or  at  a  slight  distance 
from  it,  and  near  it  other  new  ones ;  the  patient  begins  to  emaciate  ; 
possibly  further  operations  are  not  practicable,  marasmus  occurs,  pos- 
sibly lung  or  liver  tumors,  with  their  symptoms,  develop  ;  the  patient 
dies  from  suppuration  from  the  primary  tumor,  or  from  disease  of  in- 
ternal organs.  The  course  just  described  differs  from  that  of  carci- 
noma, because  in  the  latter  continuous  recurrence  is  the  most  frequent, 
while  in  sarcoma  the  regional  predominates,  provided  the  tumor  has 
been  entirely  extirpated.  This  may  readily  be  explained  by  the  fact 
£hat  the  bounds  of  infiltrated  carcinoma  are  much  more  difficult  to 
determine  than  are  those  of  encapsulated  sarcoma  :  hence,  ceteris  2)ciri- 
bits,  the  latter  may  be  more  certainly  removed ;  if  portions  of  sar- 
coma be  left,  of  course  there  will  be  continuous  recurrence.  After 
complete  extirpation  of  sarcoma,  years  may  elapse  before  the  regional 
recurrence,  and  sarcoma  may  always  remain  a  local  trouble  for  years, 
possibly  till  death.  I  know  one  case  of  fibro-sarcoma  of  the  back  of  the 
head,  where  it  was  twenty-three  years  from  the  development  of  the  first 
tumor  till  death  from  recurring  tumors  ;  meantime,  the  patient  was 
operated  on  five  times,  and,  on  each  occasion,  he  was  cured  for  some 
time.  From  an  old  woman  I  extirpated  a  medullary  sarcoma  (alveolar 
cancerous  form.  Fig.  138)  from  the  deltoid  muscle ;  the  wound  had 
scarcely  healed  when  a  new  sarcoma,  like  the  first,  formed  in  it ;  now 
the  woman  remained  perfectly  well  four  years,  then  a  new  tumor  came 
in  the  deltoid  ;  it  was  removed  by  an  operation,  probably  imperfect, 
and  recurred  in  the  incomplete  cicatrix  ;  exarticulation  of  the  arm  was 
followed  by  recurrence  in  the  pectoral  and  latissimus  muscles,  and 
death  from  sarcoma  of  the  lungs  and  pleurisy.  A  year  since,  I  extir- 
pated a  melanotic,  large-celled  sarcoma  from  the  scalp  of  an  old  man, 
from  whom  Schuh  had,  six  years  previously,  removed  a  similar  tumor; 
up  to  the  present  time  there  has  been  no  recurrence.  When  we  am- 
putate the  thigh  for  sarcoma  of  the  leg,  after  years  it  may  recur  in  the 
amputation-cicatrix,  and  be  followed  by  sarcoma  of  the  lungs.  The 
local  tendency  to  recur  could  be  explained  by  an  extensive  sprinkling 
of  seed  in  the  vicinity  of  a  tumor,  if  the  recurrences  succeeded  each 
other  raj)idly,  but,  when  years  elapse  between  the  recurrences,  this  ex- 


SARCOMATA. 


729 


planation  will  hardly  answer,  for  it  is  not  very  probable  that  tumor 
cells  would  lie  quiet  in  the  tissue  for  years,  and  then  suddenly  shoot 
out  like  an  old  seed.  I  know  no  explanation  for  this  mode  of  recur- 
rence. The  course  of  the  infection  is  very  peculiar  in  sarcoma ;  I  think 
I  was  one  of  the  fii'st  to  show  that  it  is  an  essential  peculiarity  of  sar- 
coma, that  it  does  not  attack  the  Ijinphatic  glands,  or  does  so  quite 
late  in  the  disease.  The  course  of  sarcoma-infection  goes  chiefly,  if 
not  exclusively,  through  the  veins — not,  as  in  carcinoma,  through  the 
lymphatic  vessels.  Sarcomata  of  the  lungs  are  mostly  of  embohc 
origin ;  it  seems  that  the  walls  of  the  veins  in  sarcoma  are  very  readily 
traversed  by  the  tumor-substance,  and  their  calibre  filled  with  friable 
masses  of  it,  which  thence  pass  into  the  lungs.  The  number  of  the 
secondary  sarcomata  is  often  enormous,  the  whole  pleura  and  peri- 
tongeum  may  be  covered  with  them.  In  this  respect,  the  melanotic 
forms  almost  appear  to  dispute  the  precedence  with  the  medullary. 
Primary,  only  partially-pigmented  tumors  are  occasionally  followed 


Fig.  140. 


Fio.  141. 


Central  ost'-osai-coma  of  the  uli'n.  fn  rn  ilie  folleciion 
of  the  surgical  clinic  ol  the  L  iiiviMsii}  al  Burliii. 


by  perfectly  black  and  also  by  perfectly  white  secondary  tumors.    S.ip 
comata  of  the  lungs  are  almost  always  of  the  granulation  variety,     ia 


730 


TUMORS. 


tlie  liver  I  have  seen  secondary,  \ery  beautifully  pigmented,  spindle- 
celled  sarcomata ;  the  forms  of  primary  and  secondary  sarcomata  thus 
vary  greatly. 

Topography  of  sarcoma.  As  the  above  general  remarks  are  in- 
sufficient for  practice,  we  must  study  more  accurately  different  for-s 
of  sarcoma  in  certain  tissues  and  in  certain  parts  of  the  body. 

Sarcomata  occur  qmte  often  in  hollow  bones  (myeloid  tumors  or 
central  osteosarcoma),  usually  in  the  form  of  giant-celled  sarcoma  ; 
they  especially  attack  the  lower  jaw,  next  tlie  tibia,  radius,  and  ulna 
(Figs.  140  to  143).  These  tumors  often  contain  mucous  cysts  and 
spherical  or  branched  osseous  formations ;  they  are  circumscribed 
nodules,  mostly  forming  in  the  medullary  cavity,  which  gradually  de- 
stroy the  bone,  but  in  such  a  way  that  new  bone  is  constantly  devel- 
oped from  the  periosteum,  so  that  the  tumor,  even  if  very  large,  often 
remains  covered  entirely  or  partially  by  a  shell  of  bone  ;  the  diseased 


Fig.  142. 


Fig.  143. 


Central  osteosarcoma  of  the  lower  jaw  of  a  girl 
nine  years  old. 


Section  of  the  spctiiutn  shown  in  Fig.  141. 


bone  then  appears  puffed  up  like  a  bladder,  and  the  tumor  does  not 
always  cause  a  complete  solution  of  its  continuity.  When  these  sar- 
comata occur  in  the  lower  extremity,  they  become  very  vascular  ; 
numbers  of  small  traumatic  aneurisms  develop  in  them,  and  a  true 
aneurismal  murmur  may  be  heard  in  them,  so  that  they  are  often  con- 
sidered and  described  as  true  bone-aneurisms.  Tlie  cystosarcomata 
and  compound  cysts,  which  are  occasionally  seen  in  bones,  especially 
in  tiie  lower  jaw,  also  in  large  hollow  bones,  have  usually  developed 
from  osteosarcomata  (Fig.  144).  Central  osteosarcomata  are  usually 
solitary,  very  rarely  generally  infectious.  In  the  lower  or  upper  jaw 
they  are  apt  to  come  at  the  time  of  the  second  dentition,  rarely  at 
the  first :  in  the  long  bones  I  have  only  seen  them  at  middle  age ;  of 
the  tumors  called  epulis  (the  word  means  located  on  the  gums)  a 


SARCOMATA. 


731 


Fio.  144. 


large  number  belong  to  tliese  giant-celled  sarcomata ;  their  location 
on  the  gums  is  generally  only  apparent ;  they  usually  spring  from 
cavities  in  the  teeth,  and  have 
started  from  carious  roots  of  teeth. 
Some  also  call  epithelial  cancer 
epulis ;  it  is  well  either  not  to  use 
such  terms  or  to  restrict  them  by 
certain  adjectives ;  as  sarcomatous, 
fibrous,  carcinomatous  epulis,  etc. 
Peripheral  osteosarcomata  or  peri- 
osteal sarcomata  (osteoid-chondro- 
mata  of  Virchow)  are  quite  ma- 
lignant; they  either  have  granula- 
tion structure  with  osteoid  tissue 
as  in  osteophites,  and  are  partly 
ossified;  or  they  are  very  large- 
celled  myxosarcomata,  also  part- 
ly ossified.  The  rapidity  of  the 
course  varies  greatly;  sarcomata 
of  the  lungs  have  been  observed 
after  them. 

Spindle-celled  sarcomata  are 
found  especially  often  in  muscles, 
fasciae,  and  cutis ;  they  are  locally 
very  infectious,  and  often  return 
after  extirpation.  Myxosarcomata 
come  in  the  cutis  and  subcutaneous 
cellular  tissue,  and  with  the  naked 
eye  are  often  difficult  to  distin- 
guish from  oedematous  soft  fibromata.  The  nerves  also  art.  relatively 
often  the  seat  of  multiple  sarcoma.  The  more  rapidly  the  primary 
tumors  have  grown,  and  the  more  "  medullary  "  their  appearance,  the 
more  dangerous  they  are.  I  find  that  all  ages,  except  perhaps  child- 
hood, are  equally  disposed  to  these  tumors. 

When  sarcoma  develops  in  a  gland  it  almost  always  contains  glan- 
dular elements,  which  may  be  greatly  changed  in  form,  and  some  of 
which  may  be  newly  formed.  Hence,  pure  adenomata  (which  arc 
very  rare)  may  be  difficult  to  distinguish  from  sarcomata  that  have  de- 
veloped in  glands  (adeno-sarcomata).  Glands  are  by  no  means  equally 
disposed  to  the  development  of  sarcoma :  we  shall  briefly  state  tlio 
localities  where  they  are  most  frequently  found. 

The  female  mamma,  more  than  any  other  gland,  is  subject  to  these 
tumors.     Sarcomata  of  the  mamma  are  roundish,  lobular,  nodulated 


Compound  cystoma  of  the  thigh,  after  PMn, 


732 


TUMORS. 


PiB.  145. 


Pig.  146. 


lai'.OBteal  sarcoma  of  the  tilna  from  a  boy.  from  the 
collection  ai  the  suruical  clinic  of  tlie  University 
at  Berlin. 


Section  of  Fig.  146. 


tumors  of  firm,  elastic  consistence ;  the  disease  may  attack  a  large  or 
small  portion  of  the  lobes  of  the  gland  ;  as  a  rule,  only  one  breast  is 
attacked  and  only  at  one  point;  at  other  times,  several  small  nodules 
occur  at  the  same  time  in  one  gland.  These  tumors  grow  very  slowly, 
cause  no  pain ;  like  all  sarcomata,  they  are  sharply  bounded  from  tlie 
healthy  parts,  hence  they  are  movable  in  the  glandular  parenchyma  ; 
when  they  grow  large  (in  the  course  of  years  they  may  attain  the 
size  of  a  man's  head)  they  almost  always  form  cystosarcomata ;  in 
the  course  of  time  they  become  softer  and  cause  pain ;  ulceration  also 
occurs.  The  anatomy  of  these  tumors  has  always  excited  great  inter- 
est. As  the  glandular  elements,  acini  as  well  as  excretory  ducts, 
were  found  in  them,  it  was  formerly  supposed  that  they  had  developed 
in  the  tumor ;  hence  these  tumors  were  called  partial  hypertrophies 
of  the  mamma.  I  consider  this  view  incorrect,  and  think  that,  by  ex- 
amining a  great  many  of  these  tumors,  I  have  satisfied  myself  that  pri- 
marily and  chiefly  there  is  a  development  of  sarcoma  in  the  connective 
tissue  around  the  acini,  the  latter  being  preserved,  although  they  may 
be  changed  in  various  ways.  The  distention  of  the  gland-ducts  causes 
cysts,  at  first  slit-shaped,  subsequently  more  roundish,  with    muco 


SARCOMATA.  733 

serous  contents,  who?e  development  we  shall  immediately  follow. 
The  tissue  of  the  neoplasia  itself  is  usually  composed  of  small,  round, 
spindle-shaped,  rarely  of  branched  cells,  with  considerable  developed, 
fibrous,  sometimes  gelatinous  intercellular  substance.  In  some  of 
these  tumors  the  fibrous  tissue  may  be  so  prevalent  that,  in  consist- 
ence and  constitution,  the  entire  tumor  may  resemble  fibroma.  Acci- 
dental cartilaginous  and  osseous  tissue  are  occasionally  observed,  but 
are  very  rare,  and  have  no  influence  on  the  course  of  the  disease.  If 
the  growth  of  these  tumors  were  regular  throughout,  the  excretory 
ducts  and  acini  of  the  glands  would  be  equally  enlarged  or  compressed ; 
for,  if  you  imagine  a  part  of  the  gland,  say  a  lobule,  spread  out  as  a 
surface,  and  suppose  the  basis  to  which  this  surface  is  attached  en- 
larging, the  epithelial  surface  must  also  enlarge.  But  the  glands 
may  be  regarded  as  surfaces  bulged  out  in  many  places,  so  that  this 
representation  is  quite  proper.  Such  a  regular  growth  in  all  parts  of 
a  gland  never  or  very  rarely  occurs ;  the  result  is,  that  fi-equently  only 
the  excretory  ducts  elongate  or  enlarge  much ;  this  induces  the  slit^ 
shaped,  elongated  cysts,  visible  to  the  naked  eye ;  but,  by  simultane- 
ous distention  of  the  glandular  acini,  roundish  cysts  are  often  formed. 
In  this  stretching  of  the  sacculated  glandular  surface,  the  epithelium 
increases  and  develops  to  a  higher  stage,  inasmuch  as  the  small,  round 
epithelial  cells  of  the  acini  increase  greatly,  and  change  to  a  layered- 
cylindrical  epithelium.  The  glandular  substance  thus  altered  secretes 
a  muco-serous  liquid,  a  very  minute  portion  of  which  is  spontaneously 
evacuated  from  the  nipple,  while  most  of  it  is  retained  in  the  tumor, 
and  serves  to  dilate  the  already  distended  glandular  cavity  (retention 
and  secretion  cysts). 

Then  the  tumor-substance  again  grows  into  these  cysts  in  the  form 
of  lobulated,  leaf-hke  proliferations  (cystosai'coma  phyllodes,  prolife- 
rum ;  John  31uller)^  so  that  the  cut  surface  may  thus  acquire  quite  a 
complicated  appearance. 

The  relation  of  this  cyst-development  to  the  sarcoma  (the  nature 
and  course  of  the  disease  is  not  much  influenced  by  the  former)  varies 
greatly  in  these,  as  in  all  cystosarcomata. 

Mammary  and  cysto  sarcomata  are  not  very  rare,  but  are  far  less 
frequent  than  the  cancers  of  the  breast,  which  we  shall  hereafter  men- 
tion. The  disease  is  most  frequent  in  young  married  women,  but 
also  occurs  shortly  before  puberty — rarely  after  the  fortieth  year  of 
life.  The  growth  of  these  tumors  is  very  slow,  and  is  painless  before 
they  become  large;  later,  however,  they  are  accompanied  by  piercing 
pains ;  as  the  tumor  may  grow  as  large  as  a  man's  head,  and  ulcerate, 
it  may  prove  very  troublesome.  Some  of  these  sarcomata  have  the 
peculiarity  of  swelling,  and  becoming  slightly  painful  shortly  before 


734 


TUM0U5. 


and  during  menstruation.  In  this  disease,  the  general  health  is  not 
affected,  except  that  iu  large  ulcerated  tumors  the  patients  emaciate, 
become  anaemic,  and  acquire  a  suffering  look.     The  course  of  the  dis- 


J^W   147. 


Kniiii  -in  I'ltMio-sarcoma  of  the  female  breast :  a,  dilat'ition  of  the  excretory  dncts;  b.  of  the 
a  iiii.  iiiUiriiuied  (JO  diametors ;  c,  a  diutcd  acimis*  of  the  mammary  i,'l.ind,  wit'i  cyliii'lrical 
epillicliu.il ;  Intermediate  Bub^tauce  resembling  granulutiou-tissue,  magnitied  ;3oO  diaineiers. 

ease  may  vary ;  there  are  not  a  few  cases  where  small  sarcomata  of 
the  breast,  which  perhaps  came  after  the  first  confinement,  spontane- 
ously disappeared  in  the  course  of  time,  or  else  remained  for  the  rest 
of  life  without  doing  any  harm  ;  but  in  most  cases  these  tumors  grow 
gradually,  until  they  are  operated  for;  if  this  is  not  done  till  late,  when 
the  tumors  have  become  large,  and  the  women  have  attained  old  age, 
tliey  may  become  infectious.  In  young  girls  and  women,  when  a 
slowly-growing  sarcoma  of  the  mammary  gland  is  extirpated,  it  does 
not  usually  reappear.  If,  however,  the  sarcoma  first  appears  between 
the  thirtieth  and  fortieth  years,  we  have  to  fear  general  sarcoma  infec- 
tion, or  actual  transformation  to  carcinoma  by  epithelial  proliferation. 
I  consider  it  advisable,  in  all  cases,  to  extirpate  these  mammarv  sar 


SARCOMATA.  735 

comata  early,  as  we  never  know  exactly  what  their  future  course  will 
be.  The  diagnosis  is  often  difficult;  small,  nodular,  lobulated  hard- 
enings  may  occur  in  the  breasts  from  chronic  inflammation,  especially 
during  and  after  lactation,  which  pass  off  spontaneously,  or  under  the 
use  of  iodine.  We  often  have  to  decide  from  the  course  whether  the 
case  is  one  of  chronic  inflammation  which  may  subside,  or  an  actual 
tumor.  Even  the  most  accurate  anatomical  examination  is  here  of  no 
avail,  for  young  sarcoma-tissue  cannot  be  distinguished  from  inflam- 
matory neoplasia.  This  is  another  case  where  the  boundary  between 
chronic  inflammatory  neoplasi^e  and  tumors  cannot  be  accurately 
di'awn. 

A  second  organ,  in  which  adeno-sarcoma  and  adenoma  develop,  is 
the  salivary  gland.  The  tumors  that  form  here  are  usually  quite  firm 
and  elastic,  are  tolerably  movable  and  grow  very  slowly  ;  they  occur 
in  the  parotid  more  frequently  than  in  the  sub-maxillary  gland,  and 
very  rarely  in  the  sublingual.  As  seen  by  the  naked  eye,  the  anatomi- 
cal characteristics  vary  greatly  ;  the  tumor  is  always  distinctly  bounded 
by  a  capsule,  which  is  very  intimately  connected  with  the  gland-tissue. 
The  substance  of  the  tumor  may  be  of  pulpy,  cartilaginous  or  fibrous 
consistence,  it  may  be  ossified,  or  calcified ;  it  often  contains  cysts 
of  briny,  gelatinous,  or  serous  fluid.  Histological  examination  of  these 
tumors  shows  that  their  softer  parts  consist  of  spindle-cells  and  stellate 
cells,  sometimes  with  a  slight,  again,  with  a  large  amount  of  mucous 
or  cartilaginous  intercellular  substance ;  there  are  also  newly-formed 
gland-tubes.  In  rare  cases,  the  tumor  consists  almost  exclusively  of 
cartilage,  but  very  frequently  there  is  some  sarcomatous  tissue  present. 
These  tumors  may  develop  from  the  time  of  puberty  to  the  fortieth 
year ;  they  grow  very  slowly  and  painlessly,  and  particularly  slowly 
when  they  do  not  form  till  middle  age.  Although  they  never  retio- 
gr£ide,  small  tumors  (say  as  large  as  an  egg)  of  this  variety  may  cease 
growing  late  in  life.  If  these  tumors  be  extirpated  from  young  pa- 
tients, as  a  rule,  they  do  not  return.  But  later  in  life  they  often  recur 
after  extirpation,  and  return  so  quickly,  that  they  gradually  grow 
deeper  in  the  neck,  and  finally  become  inaccessible  to  the  knife  ;  the 
neighboring  lymphatic  glands  of  the  neck  are  infected,  and  the  disease 
assumes  the  character  of  carcinoma  ;  the  adeno-sarcoma  becomes  cancer 
of  the  gland.  General  development  of  sarcoma  scarcely  takes  place 
from  these  tumors.  From  the  course  above  described,  we  might  fonn 
the  rule  of  removing  these  tumors  early  in  young  patients,  but  in  older 
ones  of  not  being  too  hasty  about  extirpation,  as  rapid  recurrence  is 
to  be  feared,  while  occasionally  the  primary  tumors  grow  slowly.  Sar- 
3omata  of  the  sahvary  gland  are  not  frequent.  Similar  myxo-sarco- 
mata  and  myxo-chondromata  occasionally  develop  in  the  oral  mucous 
iriembrane. 


736  TUMORS. 


9.— LYMPIIOMATA. 

Tmksk  jeoplasiae  are  very  difficult  to  define  accurately.  According 
to  the  niodc  of  development  we  may  assume  a  secondary  inflammatory 
swelling  of  the  lymph-glands  from  infection,  and  an  idiopathic  hyper^ 
plasia.  In  diseases  from  the  most  varied  causes,  the  l^nnphatic  glands 
almost  always  present  a  similar  appearance  ;  they  are  enlarged,  more 
succulent,  firmer  than  normal.  The  microscopic  examination  of  lym- 
phoma shows  the  following  appearances,  if  made  from  a  hardened, 
properly -prepared  specimen  :  All  the  cellular  elements  are  multiplied 
and  enlarged  ;  the  lymph-cells  in  the  alveoli,  the  connective-tissue 
cells  of  the  trabecular,  the  capsules  of  the  alveoli  and  the  net-work ; 
thus,  the  structure  of  tlie  gland  is  gradually  lost  entirely ;  the  whole 
organ  becomes  a  mass  of  lymph-cells,  although  a  fine  net-Avork  is  gen- 
erally preserved,  into  which  the  hard  connective  tissue  of  the  capsule 
and  of  the  trabecular  is  also  transformed,  while  the  blood-vessels  are 
preserved,  and  tlieir  walls  greatly  thickened  (Fig.  148)  ;  the  cellular 
infiltration  may  be  so  great,  that  an  exact  distinction  between  lym- 
phoma and  glio-sarcoma  (Fig.  148)  may  be  impossible  at  some  points. 
Usually  there  are  glands  of  various  sizes,  and  we  find  the  large  ones 
of  the  same  structure  as  the  smaller.  Keitlier  the  macroscopic  nor 
microscopic  appearances  will  determine  exactly  the  causes  of  the 
hyperplasia,  whether  it  be  idiopathic  or  due  to  chronic  inflammation ; 
we  can  only  say,  in  general,  that  glands  much  enlarged  by  chronic 
inflammation  more  frequently  contain  abscesses  and  caseous  foci  than 
those  which  are  apparently  idiopathic  hyperplasia.  Perhaps  I  am  too 
conscientious  in  using  the  term  "  idiopathic  disease  of  the  lymphatic 
glands  ;"  for  in  many  of  these  cases  we  can  discover  no  peripheral  irri- 
tation, although  many  things  speak  in  favor  of  the  disease  of  tlie 
glands  being  secondary ;  it  is  possible  that  slight,  temporary  inflam- 
mations have  existed,  that  have  excited  disease  of  the  glands,  and 
have  disappeared  before  the  afiection  of  the  glands  has  shown  itself. 
We  formerly  spoke  of  a  similar  secondary  plastic  process  in  the  lym- 
phatic glands,  after  the  primary  peripheral  irritation  had  ceased,  as 
being  a  chief  symptom  of  scrofula ;  hence  we  might  term  lymphomata 
as  typical  scrofulous  tumors  (scrofulous  sarcoma,  J3.  von  Lanyenbech), 
liCt  us  study  them  further,  anatomically  and  clinically. 

For  a  long  time  the  glands  preserve  their  kidney-shape  till  finally, 
as  they  continue  to  grow,  this  also  is  lost,  and  the  adjacent  glandulai 
tumors  unite  to  form  a  lobulated  mass.  To  the  naked  eye,  the  extir- 
pated tumors  appear  roimdish,  oval,  or  kidney-shaped ;  on  section, 
they  are  of  a  light,  grayish-yellow  color,  which,  on  exposure,  changes 


LYMPHOMATA, 
Fio.  148. 


73^ 


From  the  cortical  layer  of  a  hyperplastic  cervical  lymphatic  ^liind.  Magnified  ^50  diametere,  a 
a,  section  of  vessels  with  thickened  walls,  brushed-uut  alcohol  preparation. 

to  a  yello wish-red.  These  tumors  are  firm  and  elastic ;  they  are  easily 
diagnosed,  from  their  locality.  All  lymphatic  glands  are  not  equally 
disposed  to  this  disease  ;  the  most  frequently  affected  are  the  cervical 
either  on  one  or  both  sides  ;  more  rarely  the  axillary  and  inguinal, 
most  rarely  the  abdominal  and  bronchial.  These  tumors  are  hardly 
ever  congenital,  but  they  may  occur  from  the  first  to  the  sixtieth  year, 
although  they  are  most  frequent  between  the  eighth  and  twentieth. 
Not  unfrequently,  hyperplasia  of  the  lymphatic  glands  is  multiple ; 
but  only  one  or  a  fevr  glands  in  the  neck  may  be  affected  ;  if  this  be 
the  case,  the  tendency  to  such  neoplasia  runs  out  in  the  course  of 
time,  while  the  tumors  which  have  grown  painlessly,  and  continued 
free  from  pain,  have  their  growth  arrested,  and  ma}'^  be  carried  till 
death.  In  rare  cases,  the  new  formation  appears  almost  at  the  same 
time  in  all  the  lymphatic  glands  of  one  or  both  sides  of  the  neck,  so 
that  the  latter  is  thickened,  and  the  movements  of  the  head  are  much 
impeded  ;  if  these  tumors  continue  to  grow,  they  finally  compress  the 
trachea  and  cause  death  by  suffocation  ;  but  even  in  these  severe  cases 
there  is  occasionally  a  spontaneous  arrest  of  the  disease,  and  then  even 
large  tumors  of  this  kind  may  be  successfully  extirpated ;  some  of 
these  glands,  too,  are  finally  destroyed  by  ulceration  tmd  caseous  de- 
generation. 

The  worst  cases  are  those  where  the  tumors  quickly  grow  to  large 
medullary  tumors  (not  unfrequently  under  the  form  of  fasciculated 
medullary  fungi),  and  where  the  neighboring  tissue  is  also  changed 
to  lymphoma.  Patients  with  such  tumors  rarely  escape ;  anaemia  comes 
on,  the  nutrition  is  impaked,  and  hypertrophy  of  the  spleen  may 
appear,  and  the  patient  die  of  excessive  anaemia  and  marasmus. 

[These  malignant  lymphomata  are  to  be  regarded  as  true  medul- 
lary sarcoma  of  the  lymph-glands.  But,  in  regard  to  the  nomen- 
48 


738  TUMORS. 

clature  of  tumors  of  the  lymphatic  glands,  we  find  great  confusion, 
chiefly  induced  by  the  expression  lympliosarcotna.  For  while,  by 
this  term,  some  understand  sarcomata,  whose  structure  is  like  that 
of  lymphatic  glands,  others  mean  all  primary  tumors  of  these 
glands,  no  matter  what  is  their  structure,  if  their  course  resembles 
that  of  sarcoma.  Hence  I  would  strike  out  the  name  lymphosar- 
coma, and  call  tumors  with  sarcoma  formation,  which  develop  in 
the  lymph-glands,  sarcoma  of  the  lymphatic  glands.  The  name 
lymphoma  would  remain  for  hyperplasia  of  these  glands,  whether 
due  to  increase  of  lymph-elements,  or  to  their  enlargement.  At 
first,  sarcomata  of  the  lymph-glands  are  like  true  lymphomata,  ana- 
tomically and  clinically.  But  they  differ  from  malignant  lympho- 
mata, because  the  growing  tumor  quickly  bursts  the  gland-capsule, 
and  attacks  the  surrounding  parts,  becoming  adherent  to  them,  and 
not  unfrequently  causing  ulceration  and  extensive  destruction  of 
the  skin.  They  are  most  prone  to  recurrence,  and  belong  to  the 
most  dangerous  form  of  tumors.  Quite  lately  I  have  seen  several 
cases  where  metastatic  tumors,  with  alveolar,  round-celled  sarcoma 
structure,  were  found  in  the  lungs  and  spleen. 

Besides  these  malignant  sarcomata  of  the  lymph-glands,  there 
are  maUgnant  lymphomata  {Billroth), >y;\nch.,  in  another  way,  are 
scarcely  less  dangerous,  though  not  possessing  all  the  clinical  pe- 
culiarities of  malignant  tumors — among  others,  unlimited  tendency 
to  spread,  and  consequent  destruction  of  organs.  These  tumors 
are  true  hyperplasias  of  the  lymph-glands,  the  proliferation  of  the 
elements  attacking  a  group  of  glands  at  once,  but  remaining  limited 
to  the  glands,  so  that  the  capsule  is  not  ruptured  or  the  neighbor- 
ing parts  attacked.  The  glands  first  attacked  grow  to  a  tumor 
composed  of  several  nodules,  which  is  at  first  painless.  Then  an 
adjacent  group  is  attacked,  and  the  disease  spreads  to  the  other 
side  of  the  body,  and,  finally,  to  the  mediastinal  and  retroperitoneal 
glands.  Occasionally,  by  this  time,  the  patient's  general  condition 
has  suffered  ;  the  skin  is  pale,  the  body  emaciated,  there  is  oedema 
of  the  limbs  ;  later,  they  cough,  have  hectic,  and  severe  pain  in 
some  of  the  tumors,  and  finally  die  from  general  exhaustion,  bloody 
diarrhoea,  cough,  with  purulent  expectoration,  etc.  But  this  result 
is  not  the  rule  ;  some  patients,  especially  old,  strong  men,  have  ma- 
lignant lymphoma,  and,  in  spite  of  enormous  development  of  the 
tumors,  maintain  good  general  condition.  They  may  suffer  solely 
from  displacement  and  compression  of  the  larynx  and  trachea,  and 
it  is  astonishing  what  patients  can  stand  in  this  way,  when  the  com- 
pression comes  on  gradually.  Usually  these  jiatients  die  suddenly 
from  suffocation,  often  after  severe  exertion,  like  goitre  patients. 


LYMPHOMA  TA.  739 

On  autopsy,  we  usually  find  several  groups  of  glands,  but  some- 
times only  those  of  one  side  of  the  neck,  immensely  enlarged  ; 
similar  tumors  are  found  in  the  mediastinum  and  abdomen.  But 
sometimes  true  lymphoma  nodules  are  found  in  the  internal  organs, 
in  the  lungs,  spleen,  liver,  kidneys,  and  even  in  the  spongy  bones, 
which  may  be  regarded  as  metastases.  These  tumors  are  classed 
as  hard  or  soft,  according  to  their  consistence  ;  the  former  are  a 
higher  form  of  development  than  the  latter,  but  the  two  are  dis- 
tinctly characterized  from  the  start :  the  soft  have  a  gray-red- 
dish medullary  appearance,  the  hard  are  pure  white  or  grayish- 
white,  like  fibroma.  The  same  difference  is  found  in  the  metastatic 
tumors. 

In  the  soft  as  in  the  hard  lymphomata,  the  lymph-vessels  are 
permeable  ;  in  the  former  they  are  even  easy  to  inject.  The  general 
structure  of  the  gland  is  preserved  ;  in  the  channel,  large,  multi- 
nucleated, often  giant  cells,  are  found.  In  the  hard  forms,  the 
reticulum  particularly  is  thickened  and  changed  to  sclerosed  con- 
nective tissue  ;  in  the  soft,  there  is  mostly  new  formation  of  lymph- 
cells  and  dilatation  of  the  framework.  The  disease  usually  begins 
in  the  cervical  glands  of  one  side,  and  sometimes  remains  limited 
there.  Not  unfrequently  the  glands  of  the  throat  and  of  the  ton- 
sils are  attacked,  and  early  cause  difllculties  of  swallowing  and 
respiration.  More  rarely  the  affection  begins  in  the  axilla  ;  least 
often  in  the  groin.  Sometimes  a  slight  iri-itation  is  the  exciting 
cause,  as,  in  one  patient,  a  bee-sting  on  the  hand  started  an  acute 
lymphangitis  and  adenitis  of  the  axillary  glands  ;  this  latter  did  not 
subside,  but  grew  like  a  tumor.  In  other  cases  a  slight  glandular 
swelling  is  caused  by  an  irritation  continued  several  months  ;  sud- 
denly the  glands  begin  to  grow  rapidly,  and  neighboring  groups  are 
attacked.  Usually  there  is  no  perceptible  cause.  Scrofulous  per- 
sons, in  whom  chronic  glandular  hyperplasia  is  so  common,  are  not 
disposed  to  malignant  lymphoma  ;  hence,  we  may  decide  against 
the  disease  being  of  this  nature,  if  we  find  the  marks  of  scrofula. 
No  age  is  exempt — it  occurs  in  children  of  a  few  months  or  in  per- 
sons sixty  years  old  ;  but  healthy-looking  persons,  in  early  puberty, 
seem  most  prone.  Some  cases  had  been  preceded  by  intermittent 
fever  that  had  left  no  sequelfe. 

The  great  resemblance  of  malignant  lymphoma  to  so-called 
leucaemia  lymphatica,  in  which  also  there  are  tumors  of  the  spleen 
and  other  organs,  has  often  been  observed,  and  the  affection  has 
been  caWed 2yseudoleuccemia  (Trousseau).  But  the  two  diseases  are 
distinct  in  the  structure  of  the  hyperplastic  glands.  A  more  im- 
portant point  is  the  absence,  in  malignant  lymphoma,  of  the  char- 


740  TUMORS. 

acteristic  of  leucaemia  ;  i.  e.,  increase  of  the  white  corpuscles.  In 
the  last  stages  of  pseiidoleucsemia,  as  in  marasmus  from  any  cause, 
the  proportion  of  colorless  corpuscles  is  increased,  but  never  so 
markedly  as  in  leucaemia  proper.  Moreover,  patients  with  the 
latter  disease  are  ailing  from  its  commencement  or  even  before  ; 
while  those  with  malignant  lymphoma,  even  when  the  tumors  are 
large,  are  usually  strong  and  feel  well.  The  disease  is  local.  When, 
in  some  cases,  there  is  marked  leucocythoemia,  it  is  probably  due  to 
special  pathological  conditions  ;  for  instance,  from  the  growth  of 
the  tumor  into  the  axillary  vein,  etc.  In  true  leucaemia,  also,  the 
medulla  of  the  bones  is  imj^licated,  while  in  malignant  lymphoma 
it  is  not. 

There  are  other  hyperplasias  of  the  gland  that  can  neither  be 
termed  chronic  scrofulous  lymphadenitis  nor  secondary  glandular 
swellings.  Of  course,  we  do  not  mean  those  glandular  enlarge- 
ments near  a  neoplasia,  or  their  symptomatic  enlargements.  These 
tumors  have  the  formation  of  hypertrophied  glands,  but  no  sup- 
purative or  caseous  degeneration  ;  they  are  movable,  painless, 
hard,  isolated  ;  they  usually  grow  in  the  neck,  perhaps  to  the  size 
of  a  hen's  egg — so  that  we  might  suspect  malignant  lymphoma  ; 
but  their  growth  ceases  suddenly,  and  other  groups  do  not  become 
diseased,  and  the  tumors  remain  stationary  ;  if  removed,  they  do 
not  return. 

From  the  above,  you  see  the  prognosis  varies.  In  the  com- 
mencement you  can  never  tell  what  will  become  of  a  lymjjhatic- 
gland  tumor.  Rapid  growth  and  adhesion  to  the  surrounding  parts 
and  skin  indicates  development  of  the  most  malignant  medullary 
sarcoma,  and  a  very  active  course.  If  several  gi'oups  of  glands  en- 
large, even  if  there  is  malignant  lymphoma,  a  fatal  result  is  certain; 
but  the  duration  of  the  disease  depends  on  the  rapidity  of  the 
growth,  and  the  complications  caused  by  the  location  of  the  tumor 
and  the  extension  to  internal  organs.  Tlie  softer  forms  seem  to 
grow  more  rapidly,  and  to  cause  more  metastases  ;  young  persons 
and  those  in  whom  the  disease  is  extensive  at  the  start  die  sooner 
than  persons  beyond  forty  years.  Cases  with  rapid  growth  usually 
die  within  two  years  ;  others,  probably  the  majority,  last  four  or 
five  years.  Malignant  lymphomata  furnish  a  large  proportion  of 
mediastinal  tumors,  which  cause  the  most  varied  symptoms,  and 
always  prove  fatal  in  three  or  four  years. 

Of  all  the  lymphomata,  the  only  ones  free  from  danger  are  the 
last-mentioned,  simple  hyperplasia,  enlargement  of  single  glands 
not  going  beyond  a  certain  size,  which  may  remain  stationary  for 
life,  and  do  not  suppurate  or  become  caseous.    This  afrection  begins 


LYMPHOMATA.  741 

at  the  commencement  of  puberty  or  sooner  ;  after  the  thirtieth  year 
all  such  tumors  are  suspicious. 

The  treatment  of  the  above  diseases  at  first,  until  we  are  sure  it 
is  not  a  scrofulous  swelling  of  the  gland,  is  internal — such  as  cod- 
liver  oil,  brine-baths,  and  preparations  of  iodine,  unless  it  is  contra- 
indicated  ;  with  commencing  anaemia,  iron  is  indicated  alone,  or 
combined  with  iodine.  In  rare  cases  under  this  treatment,  recent 
lymph-tumors  recede.  LucJce  made  parenchymatous  injections  of 
tincture  of  iodine  with  good  effect ;  according  to  my  experience, 
the  tumors  are  thus  diminished,  but  chiefly  by  the  formation  of 
abscesses  which  are  opened,  and  the  resulting  cicatrices  contract.  I 
have  rarely  seen  disappearance  of  the  tumor  by  absorption  without 
suppuration.  The  same  is  true  of  the  constant  current.  Of  exter- 
nal remedies,  mercury  has  almost  no  effect  ;  painting  with  tincture 
of  iodine  is  most  efficacious  ;  it  sometimes  causes  periadenitic  swell- 
ing, adhesion  of  the  glands  to  each  other  and  to  the  skin,  so  that 
subsequent  extirpation  may  be  difficult.  Bcmm  has  tried  continued 
compression  by  a  special  apparatus  ;  this  requires  time,  and  is  rarely 
effectual.  If  it  is  a  case  of  simple,  long-stationary  swelling  of  the 
lymphatic  glands,  it  is  best  to  extii'pate  them  all,  or  at  least  the 
larger  ones.  In  malignant  lymphoma,  in  some  cases  Fowler's  solu- 
tion of  arsenic  has  proved  effectual,  by  parenchymatous  injection 
and  internally,  in  increasing  doses  till  symptoms  of  poisoning. 
Under  this  treatment,  large  tumors,  even  in  the  chest  and  abdo- 
men, receded  in  a  few  weeks,  usually  with  severe  fever.  We  begin 
the  treatment  with  ten  drops  of  Foider''s  solution  internally,  and  in- 
ject two  drops  into  the  tumor  every  day  ;  every  third  day  the  inter- 
nal dose  should  be  increased  by  two  drops  ;  the  injections  should 
be  given  in  different  glands,  and  gradually  increased  to  four  or  six 
drops.  If  symptoms  of  poisoning  occur,  the  doses  should  be  re- 
duced, but  never  suddenly  Avithdrawn,  I  have  seen  many  aston- 
ishing results  from  ai'senic  treatment,  even  in  cases  of  recurrence, 
but  no  permanent  cures.  In  sarcoma  of  the  lymphatic  glands 
arsenic  is  much  less  useful  ;  but  in  simjile  glandular  hyperplasia 
injections  are  beneficial. 

In  the  "Wiener  medicinische  Wochenschrift,"  1871,  No.  14, 
Billroth  published  about  the  first  successful  case  of  treatment  by 
arsenic.  A  woman  forty  years  old  was  sick  for  ten  months  with 
the  glands  of  the  axilla,  neck,  and  groin  as  large  as  an  ^^g  or  a  fist. 
Quinine  was  ineffectual,  but  after  using  Fowler's  solution  of  arsenic 
for  a  fortnight  the  glands  had  begun  to  diminish  in  size,  and  at  the 
end  of  two  months,  when  dismissed  from  treatment,  there  remained 
only  a  gland  as  large  as  a  filbert  on  the  neck. 


742  LYMPnOMATA. 

Winiioarter  reports  five  other  cases,  in  three  of  which  there  was 
no  benefit ;  in  one  the  glands  disappeared  rapidly,  but  the  patient 
died  from  inflammation  induced  by  the  removal  of  a  small  gland 
from  the  neck  for  the  purpose  of  verifying  the  diagnosis  ;  one  case 
was  still  under  treatment. 

In  the  commencement  of  the  treatment  the  remedy  was  well 
borne  ;  the  first  sign  of  its  action  on  the  glands  was  that  they  be- 
came softer,  and  after  eight  or  ten  days  wei'e  almost  always  pain- 
ful. Subsequently,  when  the  treatment  was  successful,  the  glands 
rapidly  became  smaller,  and  at  the  same  time  harder  and  gradually 
less  sensitive.  In  one  case  there  were  inflammation  and  suppuration 
of  the  tumors. 

Operating  is  of  no  use  in  malignant  lymphoma.  Recurrence  is 
usually  so  rapid,  that  operations  cannot  keep  pace  with  it,  and,  after 
numerous  operations,  the  patients  die  sooner  than  if  left  alone  ;  it 
would  only  be  advisable  where  disease  of  a  few  glands  had  run  its 
course.  But  we  often  have  to  make  partial  extirpation,  on  account 
of  difficulty  of  respiration  due  to  tumors  in  the  tonsils  and  neck 
near  the  trachea. 

In  sarcoma  of  the  lymph-glands,  in  the  early  stages,  we  may 
operate,  and  effect  at  least  temporary  benefit.] 

The  operation  itself  will  be  well  borne  in  cases  where  the 
glands  may  be  isolated,  and  still  preserve  their  capsules.  I  have  ex- 
tirpated (or  rather  dug  out  with  my  finger)  twenty  or  more  isolated 
glands  from  the  neck  of  the  same  patient  without  subsequent  recur- 
rence ;  but  when  the  glands  unite  to  one  mass,  and  are  soft,  it  is  on 
the  one  hand  a  sign  of  rapid  growth,  and  local  recurrence  may  be  cer- 
tainly expected ;  on  the  otlier  hand,  it  will  greatly  increase  the  diffi- 
culty of  operation.  Sometimes  lymphomata,  developing  deep  in  the 
neck  in  young,  otherwise  healthy  persons,  grow  behind  the  jaw  into 
the  throat  and  implicate  the  tonsils  and  pharynx ;  they  usually  soon 
prove  fatal ;  the  operations  that  might  relieve  them  are  so  dangerous 
that  they  rarely  prolong  life. 

Of  the  other  glands,  which,  according  to  recent  observations,  are 
to  be  classed  in  the  lymphatic-gland  system,  the  tonsils  alone  are 
subject  to  hyperplastic  disease ;  but  this  hypertrophy  of  the  tonsils 
which  is  common,  and  in  children  and  young  persons  is  quite  fre- 
quent, more  resembles  chronic  inflammatory  secondary  swelling  of  the 
lymphatic  glands ;  it  is  usually  the  result  of  chronic  catarrh  of  the 
pharynx,  while  the  reverse  is  often  falsely  considered  to  be  the  case, 
namely,  that  the  hypertrophied  tonsils  are  the  cause  of  the  pharyngeal 
catarrh  ;  hence,  in  such  cases,  extirpation  does  nothing  for  the  cliief 
trouble,  the  frequent  inflannnations  of  the  throat. 


TUMORS.  743 

Hypertrophy  of  the  thymus  gland  does  occur,  but  is  rare.  The 
analogous  diseases  of  Peyer's  glands  and  the  spleen  have  no  special 
interest  in  surgery. 

Lymphoma  also  occurs  in  tissues  which  do  not  belong  to  the  lym- 
phatic  glands.  I  class  as  lymphomata  all  those  medullary  tumors, 
usually  soft,  in  which,  by  hardening  and  preparation,  we  may  see  a 
net-work  analogous  to  that  of  the  lymphatic  glands.  In  this  sense,  I 
have  seen  lymphomata  of  the  upper  jaw,  scapula,  cellular  tissue,  eye, 
etc. ;  tumors  whose  structure  frequently  can  only  be  imperfectly  dis- 
tinguished from  granulation  sarcoma  (especially  from  Yirchow's  glio- 
sarcoraa),  and  which  form  their  ordinary  medullary  consistency,  are 
briefly  called  "  medullary  fungi."  According  to  my  experience,  the 
mixture  of  the  above  forms  has  no  special  prognostic  significance,  as 
these  tumors  are  alike  malignant  and  infectious ;  but  the  importance 
of  the  most  accurate  examination  of  these  tumors  should  not  on  this 
account  be  limited  or  undervalued ;  during  the  last  ten  years  we  have 
learned  interesting  and  important  clinical  differences  for  the  more  ac- 
curate distinction  between  sarcoma  and  carcinoma.  Ten  years  ago 
we  could  not  have  spoken  as  decidedly  about  sarcoma  and  lymphoma 
as  we  now  may.  What  we  now  include  under  "lymphomata"  were 
formerly  treated  of  jjartly  under  glandular  hyperplasiie,  partly  as  sar- 
comata, partly  as  medullary  fungi. 


LECTURE     XLIX. 

10.  Papillomata. — 11.  Adenomata. — 12.  Cysts  and  Gystomata.—YoWwwhxr  Cysts  of  the 
Skin  and  Mucous  Membranes. — Neoplastic  Cysts.— Cysts  of  the  Tliyroid  Gland.— 
Ovarian  Cysts. — Blood-Cysts. 

10.  PAPILLOMATA— PAPILLARY  HYPEETROPHY. 

HiTHEKTo  we  have  spoken  exclusively  of  new  formations  from  the 
series  of  connective-tissue  substances,  muscles  and  nerves.  We  now 
pass  to  the  neoplasiae  of  true  epithelium,  derived  from  the  upper  and 
lower  germ-layer  of  the  embryo. 

The  epitheliums  form  a  great  part  of  two  normal  tissues,  namely, 
of  the  papillae  (tufts,  intestinal  villi),  and  of  the  glands;  the  former 
are  wavy  or  finger-like  elevations,  the  latter  pouched  or  cylindrical 
sinkings  in  of  the  membranes,  which  the  epithelial  covering  accurately 
follows.  Both  give  the  physiological  paradigms  for  certain  forms  of 
tumors,  of  which  we  shall  mention  the  prn-ely  hyperplastic  forms  of 
the  first  Benes,^  papilloma,  and  those  of  the  second  series,  adenoma 


744 


LTMPHOMATA,   PAPILLOMATA. 


Both  are  accompanied  by  corresjoonding  connective-tissue  and  vas- 
cular neoplasia. 

Horny  papillomata  come  exclusively  in  the  cutis,  rarely  in  the 
walls  of  sebaceous  cysts.     We  may  distinguish  two  chief  forms : 

(a.)  IVarts.  Anatomically  these  consist  of  an  excessive  growth  in 
length  and  thickness  of  the  papillas.  The  epidermis  on  these  abnor 
raally  large  papillae  hornifies  in  the  form  of  small  rods,  of  which  every 
wart  is  composed,  as  you  may  readily  see  with  the  naked  eye  (Fig. 
149).  These  warts  which,  without  an}'^  known  cause,  appear  espe- 
cially often  on  the  hands  in  great  numbers,  are  rarely  larger  than  len- 
tils or  peas. 

Fig.  149. 


Wart:  a,  longitudinal  section ;  6,  cross  section.    MagniBed  20  diameters. 

(b.)  Horny  excrescences  are  to  some  extent  large  warts  ;  the  epi- 
dermis of  the  enlarged  papillse  adheres  to  a  firm  substance,  which  in- 
creases enormously,  so  that  the  horn,  whether  it  be  straight  or  twisted, 
may  grow  to  three  or  four  inches  or  more.  Although  externally  these 
horns  greatly  resemble  those  of  some  animals,  their  anatomical  struct- 
ure is  different,  for  the  latter  always  have  a  basis  of  bone.  Homy 
excrescences  are  of  a  dirty-brown  color ;  they  occur  chiefly  on  the 
face  and  scalp,  but  may  also  come  on  the  penis  and  other  parts  of  the 
body,  and  occasionally  they  grow  from  atheroma-cysts. 

The  development  of  warts  and  hornj'  excrescences  is  e\ddently  due 
to  a  general  tendency  of  the  skin  that  way.  This  is  chiefly  evident 
from  the  fact  that  as  many  as  twenty  or  thirty  warts  often  occur  on 
the  hands,  especially  of  children  shortly  before  puberty.  Irritating  ex- 
ternal influences,  affecting  the  hands  particularly,  apparently  combine 
with  the  fact  that  the  epidermis  on  the  hands  is  normally  very  thick. 


TUMORS. 


745 


The  tendency  to  horny  excrescence,  rare  as  it  is,  rather  belongs  to  ad- 
vanced age,  just  as  most  of  the  other  epidermoid  neoplasiie,  of  which 
we  shall  hereafter  speak.  Anatomically,  hystricismus  would  also  be- 
long to  the  above  forms  of  horny  growths.  Hystricismus,  or  porcupine- 
disease  of  the  skin,  is  a  peculiar  variety  of  papillary  hypertrophy,  with 
hornifying  of  the  ej^idermis  of  such  a  nature  that  porcupine-like 
formations  develop  on  the  cutis.  Like  ichthyosis  (a  scaly  thickening 
of  the  epidermis  over  the  whole  body),  this  affection  is  mostly  congen- 
ital ;  but  I  have  seen  analogous  formations  in  some  forms  of  elephan- 
tiasis nostras. 

The  predisposition  to  warts  is  entirely  devoid  of  danger,  and  in 
many  cases  ceases  spontaneously.  Popularly,  warts  are  considered 
contagious,  possibly  not  altogether  without  reason.  I  saw  a  case 
where  an  ordinary  wart  formed  on  the  side  of  a  toe,  and,  on  the 
part  of  the  neighboring  toe  lying  in  contact  with  it,  another  wart 
formed.  Horny  excrescences  are  more  important ;  although  they  occa- 
sionally break  and  fall  off  spontaneously,  they  groAV  again  if  they  are 
not  operated  upon  ;  indeed,  in  some  cases  epithelial  cancer  forms  at 
the  point  where  a  horny  excrescence  was  located. 

In  most  cases  warts  may  be  left  to  themselves.  As  in  all  dis- 
eases that  recover  spontaneously  in  the  course  of  time,  there  are 
numerous  popular  remedies :  old  women  regard  the  placing  of  a 
hand  covered  with  warts  on  the  hand  of  a  corpse,  or  rubbing  it 
with  various  leaves  and  weeds,  as  sovereign  remedies.  If  you  wish 
to  get  rid  of  certain  large  warts  that  are  peculiarly  annoying  to  their 
owners,  it  may  best  be  done  by  caustics.  For  this  purpose  I  use 
fuming  nitric  acid,  applying  it  to  the  wart  and  the  next  day  cutting 
off  the  cauterized  portion  till  a  drop  of  blood  flows,  then  repeating 
the  cauterization.  This  should  be  continued  till  the  wart  has  entirely 
disappeared. 

Horny  excrescences  can  only  be  cured  radically  by  cutting  out  the 
piece  of  skin  on  which  they  are  located. 

By  soft,  sarcomatous  papillomata,  we  mean  those  neoplasioe  that 
have  the  form  of  papilloe,  consist  of  soft  connective  or  sarcomatous 
tissue,  and  are  covered  by  an  epithelial  coating  analogous  to  that  of 
the  matrix. 

Sarcomatous  papilloe  (soft  warts)  occur  rarely  on  the  cutis,  but 
occasionally  appear  congenitively  on  one  side  of  the  face  as  cock's- 
comb-like  proliferations.  The  broad  and  also  the  pointed  condylomata 
on  the  mucous  membranes  are  products  of  syphilis  and  of  the  specific 
irritating  pus  of  gonorrhoea ;  we  do  not  class  them  among  tumors. 

Sarcomatous  papillomata  develop  much  more  frequently  on  the 


746  PAPILLOMATA. 

mucous  membranes,  esjDecially  on  the  portio  vaginalis,  more  rarely  in 
the  rectal  and  nasal  mucous  membrane.  According  to  the  surgical 
nomenclature  hitherto  in  use,  they  come  in  the  category  of  mucous 
polypi.  They  are  often  complicated  tumors,  in  which  proliferation 
and  ectasia  of  the  glands,  formation  of  sarcomatous  intermediate  sub- 
stance, and  papilloma,  all  go  together.  They  are  mostly  pedunculated 
tumors ;  occasionally  a  large  surface  of  mucous  membrane  becomes 
diseased  at  the  same  time. 

These  papillomata  are  rarely  infectious,  but  they  sometimes  recur 
after  extirpation.  The  extensive  papillomata  that  occasionally  occur 
in  the  larynx  in  children  are  perhaps  always  of  syphilitic  origin. 

I  formerly  called  tumors  with  papillary  formation,  which  develoiDed 
from  vitreous  mucous  tissue,  cylindromata  /  but  this  formation  is  not 
so  characteristic  as  I  formerly  supposed  ;  it  occurs  both  in  sarcomatous 
and  carcinomatous  tumors.  Fibromatous  and  sarcomatous  papillas 
may  develop  on  the  inner  surface  of  cysts. 


11.  ADENOMATA— PARTIAL  GLANDULAR  HYPERTROPHY. 

New  formation  of  genuine,  regularly-developed  glands  or  parts 
of" glands  is  not  frequent,  although  we  shall  hereafter  learn  that,  in 
cancer,  incomplete  development  of  glands  is  one  of  the  most  common 
forms  of  neoplasia. 

AlthoTigh  sarcoma  of  the  mamma  was  often  spoken  of  as  partial 
hyperplasia  of  the  gland,  because  glands  were  found  in  it,  of  late  it 
has  appeared  doubtful  whether  gland-acini  were  really  developed  in 
the  tumors  formerly  described  as  adenosarcoma  (i^age  731) ;  from  my 
own  observations,  I  must  consider  true  adenoma  of  the  breast  as 
very  rare ;  I  have  only  seen  it  once,  it  was  then  in  a  tubular  form. 
Forster  and  others,  however,  describe  acinous  adenoma  of  the  mamma ; 
on  account  of  this  rarity,  not  much  can  be  said  about  the  prognosis 
of  these  tumors,  which  usually  remain  small.  They  are  generally  con- 
sidered as  entirely  benignant ;  biit,  on  anatomical  gTounds,  it  seems 
to  me  probable  that  they  cannot  differ  so  much  in  prognosis  fi-om 
carcinoma. 

So  far  as  my  investigations  go,  the  so-called  hyj^ertrophy  of  the 
prostate  is  never  accompanied  by  development  of  adenoma,  but  onlv 
by  ectasia  of  the  acini  and  epithelial  h^'perplasia ;  the  frequently- ob- 
served enlargement  of  this  gland  depends  essentially  on  diffuse  or 
nodular  myoma  (page  704). 

The  glands  of  the  skin  and  some  mucous  membranes  may  also  give 


TUMORS. 


747 


rise  to  development  of  adenoma  and  adenosarcoma ;  it  is  said  that 
tumors  of  tlie  skin,  which  are  to  be  regarded  as  pure  adenomata,  may 
result  from  the  glandular  epithelium,  analogous  to  the  gland-develop- 
ment in  the  foetus.  yei'7ieuil  first  described  an  adenoma  of  the  sweai- 
glands.  I  have  never  observed  such  tumors,  but  do  not  doubt  their 
existence,  since  Hindfleisch  has  demonstrated  to  me  an  adenoma  of 
this  variety.  Those  glandular  formations  that  occur  in  the  mucous 
membrane  of  the  nose,  rectum,  and  uterus,  and  Avhich  are  embedded 
in  a  gelatinous,  cedematous  connective  tissue,  more  rarely  in  some 
other  form  of  sarcoma-tissue,  are  more  frequent. 


Fig.  150. 


From  a  mucous  polypus  (adenc.iua)  of  the  rectum  of  a  child.    Magnified  60  diameters 

Tumors  are  thus  developed  which,  in  general  terms,  are  called 
mucous  polypi:  sometimes  they  are  in  broad  folds,  sometimes  nodular 
pedunculated  tumors;  they  have  the  color  and  consistence  of  the 
mucous  membrane  whence  they  spring,  are  also  covered  with  its  epi- 
thelium, except  only  the  soft  polypi  of  the  external  auditory  meatus; 
strange  to  say,  these  are  sometimes  covered  with  ciliated  epithelium. 
All  of  these  mucous  pol}Ti  do  not  contain  glands;  they  are  usually 
absent  from  the  aural  polypi  and  the  small,  leaf-like  proliferations  ot 


748  ADENOMATA. 

Ihe  female  urethra,  the  so-called  urethral  caruncles.  The  latter  neo- 
plasige  consist  solely  of  oedematous  and  gelatinous  connective  tissue, 
with  an  epithehal  covering.  Most  mucous  polypi  of  the  nares,  large 
intestine,  and  especially  of  the  rectum,  consist  to  a  great  extent  of 
elevated  and  also  newly-formed  glands  of  the  mucous  membrane, 
whose  closed  ends  sometimes  dilate  to  mucous  cysts.  Hence,  in  the 
anatomical  system,  according  to  the  glands  they  contain,  mucous 
polypi  may  be  classed  among  pure  adenoma  (as  rectal  mucous  polypi 
in  children),  among  adeno-sarcomata  (many  nasal  mucous  polypi), 
among  oedematous  fibromata,  or,  lastly,  among  the  myxosarcomata. 
The  predisposition  to  mucous  polypi  reaches  from  infancy  to  the  fiftieth 
year.  In  children  the  disease  is  limited  to  the  rectum  and  large  intes- 
tine, where  sometimes  one,  sometimes  several  tumors  of  the  same  sort 
develop,  but  the  latter  occurs  even  oftener  in  adults  than  in  children. 
From  puberty  till  about  the  thirtieth  year,  it  affects  chiefly  the  nasal 
mucous  membrane;  sometimes  giving  rise  to  single  polypi,  again,  to 
proliferations  in  both  sides  of  the  nose ;  the  latter  is  the  more  frequent. 
Toward  the  thirtieth  year,  mucous  polypi  of  tlie  uterus  occur ;  under 
some  circumstances  they  may  change  to  cancer.  In  all  of  these 
polypi  there  is  a  great  tendency  to  recurrence,  especially  in  those  of 
the  nose,  which  often  do  not  cease  growing  till  they  have  been  re- 
moved three  or  four  times.  Generally,  in  the  course  of  years,  the 
disposition  to  these  new  formations  ceases  spontaneously,  and  they 
cease  to  recur,  or  the  smaller  ones  even  cease  to  grow,  as,  for  instance, 
in  the  uterus.  Microscopic  examination  of  these  tumors  may  give 
some  clew  to  the  prognosis,  inasmuch  as  those  tumors  which  consist- 
entirely  of  oedematous  connective  tissue  have  far  less  tendency  to  re 
cur  than  those  which  consist  of  tissue  analogous  to  inflammatory  new 
formation ;  lastly,  in  some  cases  anatomical  examination  alone  can 
prevent  mistaking  them  for  epithelial  carcinoma. 

Mucous  polj'pi  of  the  nose  are  most  readily  removed  by  tearing  them 
out  with  the  forceps  made  for  that  purpose ;  we  do  the  same  for  those 
of  the  external  auditory  meatus  [the  latter  may  be  most  efi"ectually  cured 
by  free  applications  of  liquor  ferri  persulphatis] ;  those  of  the  uterus 
and  rectum  we  may  cut  ofi"  at  the  base  with  scissors ;  if  we  fear  haemor- 
rhage, we  may  previously  apply  a  ligature,  or  employ  the  ecraseur. 

Of  the  glands  without  excretory  ducts  we  shall  here  consider  only 
the  thyroid^  as  it  is  a  true  epithehal  gland ;  adenoma  of  the  ovary  so 
often  becomes  cystoid  in  form,  that  it  may  be  more  suitably  treated 
of  in  the  next  section.  Tumors  of  the  thyroid  gland  have  long  been 
palled  goitre^  struma  (in  the  middle  ages  "  strumous  "  indicated  what 
we  at  present  call  "scrofulous").     Considering  the  anatomical  rela* 


TUMORS. 


749 


tion  of  these  tumors  to  the  gland,  we  find  that  there  are  diffuse  swell 
ings  of  the  gland,  affecting  one  or  both  lobes,  and  others  that  are  dis- 
tinctly bounded  in  the  gland,  the  latter  remaining  normal  or  but 
slightly  hypertrophic.  If  we  exclude  simple  cysts  of  the  thyroid,  so- 
called  struma  cystica,  most  other  forms  of  goitre  are  pure  adenoma  or 
cysto-adenoma.  If  the  tissue  of  these  tumors,  which  may  vary  greatly 
in  consistence,  be  not  metamorphosed  by  secondary  changes,  on  section 
it  appears  to  the  naked  eye  almost  the  same  as  the  cut  surface  of  a 
normal  thyroid  gland.  Microscopically  also  it  is  very  much  the  same- 
almost  all  thyroid  tumors  on  microscopic  examination  show  a  lar"-e 
amount  of  connective-tissue  capsules,  which  contain  a  clear  gelatinous 
substance  filled  with  more  or  less  round  pale  cells  (Fig,  151).     The 


Fig.  151. 


^////     llllw^ 


Prom  an  ordinary  Ann  tumor  of  the  thyroirl— adenoma  of  the  thyroid ;  partial  iiijecMon. 
Magnified  100  diameters. 


size  of  these  varies  greatly,  the  youngest,  which  as  yet  contain  no 
gelatinous  substance,  but  only  cells,  being  analogous  to  tlie  foetal 
thyroid  vesicles,  while  the  larger  are  six  or  ten  times  this  size.  One 
of  the  most  frequent  changes  in  goitre-tumors  is  the  formation  of 
cysts,  which  come  from  a  number  of  the  dilating  gland-vesicles  uniting, 
and  their  thick  gelatinous  contents  becoming  fluid.  But,  besides  this 
formation  of  cysts  in  goitres,  there  are  other  just  as  frequent  changes 
that  occur  almost  regularly  if  the  goitre  exists  a  long  time :  these  are 
extravasations  of  blood,  which  are  mostly  reabsorbed,  but  leave  more 
or  less  pigmentation.  Caseous  and  fatty  degeneration  is  also  frequent 
in  old  goitres ;  lastly,  calcareous  degeneration  often  occurs,  so  that  hy 
tlicse  secondary  changes  the  original  picture  of  the  tumor  may  be 
much  altered.     Goitrous  tumors,  which  ma^-  lie  in  the  middle  of  the 


750  ADENOMATA. 

Deck  or  to  both  sides,  m  numbers  or  solitary,  maj'  attain  a  consider 
able  size,  compress  the  trachea,  and  cause  suffocation.  Much  more 
rarely  the  regular  double-sided  hypertrophy  of  the  thjToid  attains  a 
dangerous  size.  Goitre  is  chiefly  remarkable  for  its  endemic  occur- 
rence ;  it  is  found  mostly  in  mountaineers :  it  is  seen  in  the  Hartz, 
Thuringian,  Silesian,  and  Bohemian  mountains,  and  in  the  Alps, 
although  not  equally  frequent  in  all  parts.  Some  valleys  of  Switzer- 
land and  of  the  Austrian  Alps  are  entirely  free  from  it.  It  has  been 
ascribed  to  the  most  different  causes,  especially  to  the  water  and  soil, 
without  any  definite  scientific  reason  having  been  found  by  accurate 
investigations.  Undoubtedly,  climatical  and  geological  conditions 
have  much  to  do  with  this  disease.  Complete  similarity  in  the  con- 
stitution (probably  often  hereditary)  of  goitrous  patients  can  hardly 
be  proved ;  a  certain  connection  with  cretinism  cannot  be  denied,  in- 
asmuch as  most  cretins  have  goitre ;  but  the  disease  is  more  frequent 
in  persons  with  well-developed  bones  and  brain.  Goitre  may  be  con- 
genital in  some  rare  cases,  but  does  not  usually  increase  till  the  com- 
mencement of  puberty ;  the  growth  rarely  continues  beyond  the  fiftieth 
year ;  goitres  which  have  continued  harmless  till  then,  usually  cease  to 
grow,  and  subsequently  cause  no  trouble ;  to  this  rule  there  are  only 
a  few  exceptions,  where  cancerous  goitre  develops  from  the  above 
hyperplastic  form,  infecting  the  neighboring  lymphatic  glands ;  these 
almost  always  prove  fatal  by  suffocation. 

[But  cases  where  death  is  due  solely  to  the  goitre  are  more  fre- 
quent than  was  formerly  supposed  :  it  may  occur  suddenly  from 
suffocation  ;  when  the  tracheal  rings  have  been  softened  or  worn 
away  by  the  tumor,  so  that  there  remains  only  a  membranous  tube, 
rapidly  turning  the  head  to  one  side  may  close  the  tube  entirely  and 
cut  off  respiration.  Hose  first  called  attention  to  this  danger,  and 
explained  the  cases  of  sudden  death.] 

It  is  scarcely  necessary  to  consider  struma  aneurysmatlca  as  a 
peculiar  variety,  as  it  is  merely  a  goitre  accompanied  by  great  dila- 
tation of  the  afferent  arteries.  Preparations  of  iodine  are  usually 
employed  against  this  disease  ;  they  are  only  efficacious,  however, 
at  the  commencement.  [They  are  used  internally  (moderate  doses 
of  iodide  of  potash)  as  well  as  externally  by  painting  and  as  paren- 
chymatous injections  into  the  tumor  ;  these  injections  of  tincture  of 
iodine  are  highly  recommended  by  Lilcke  and  Sdmalbe ;  diluted 
alcohol  maj^  be  used  the  same  way,  also  solution  of  ergotine  and 
iodoform  emulsion  (IJ  lodoformi,  glycerini,  aqua3  destilL,  ufi  partes 
equal. ;  mucilago  gum.  arab.,  qu.  sat,  ut  fiat  emulsio)  ;  these  sub- 
stances seem  to  have  about  the  same  effect.] 

In  the  first  cases  where  I  used  these  parenchymatous  injections 


TUMORS.  751 

of  tincture  of  iodine,  they  had  no  ejBFect ;  one  case  where  I  injected 
alcohol  proved  fatal  from  suppuration  of  the  goitre  and  septicaemia. 
Lately  in  some  cases  I  have  obtained  considerable  diminution  of  the 
goitre  by  persistent  injection  of  iodine  ;  twice  a  week  I  inject  one 
gramme  of  pure  tincture  of  iodine  ;  this  must  be  continued  several 
months.  Under  this  treatment  some  patients  emaciated  greatly,  so 
that  I  would  not  recommend  it  in  feeble  or  tuberculous  patients. 
Since  the  above-mentioned  unfortunate  case  I  have  not  tried  alcohol 
injections.  Stork  also  has  informed  me  that  alcohol  injections 
sometimes  excite  considerable  inflammatory  reaction,  while  after  in- 
jections of  iodine  there  is  merely  a  temporary  swelling  and  pain  ;  it 
is  prudent  at  first  to  inject  a  third  then  a  half  syringeful,  to  test 
the  individual  susceptibility  of  the  patient. 

[It  is  hardly  necessary  to  tell  you  that  these  injections  do  no 
good  in  cancerous  glands.  Not  unfrequently,  as  a  gland  has  dimin- 
ished in  size,  hectic  fever,  emaciation,  loss  of  appetite,  anaemia,  and 
debility,  have  came  on  ;  some  surgeons,  perhaps  unjustly,  regard 
these  as  signs  of  iodine-poisoning.  In  two  cases  I  have  seen  this 
condition  where  no  iodine  has  been  used  for  months  ;  it  is  probably 
due  to  absorption  of  the  diseased  gland-tissue,  as  occurs  in  malig- 
nant lymphoma  under  the  arsenic-treatment ;  in  feeble  or  tubercu- 
lous patients  it  may  prove  fatal.  These  possibly  dangerous  results 
of  medical  treatment  must  be  duly  considered  ;  their  possibility  is 
some  reason  for  preferx'ing  operation. 

Extirpation  of  hypertrophied  thyroid  glands  has  really  only  be- 
come a  frequent  operation  in  the  last  ten  years,  since  we  have 
learned  not  only  how  to  do  it,  but  also  how  to  secure  the  wound 
against  reaction  by  Lister's  dressing.  Formerly  only  those  tumors 
were  removed  which  from  their  size  or  location  endangered  life ; 
now  the  operation  is  more  freely  resorted  to,  as  we  have  found  the 
dangers  less  and  treatment  by  medicines  more  tedious  and  uncer- 
tain. 

The  best  chances  are  offered  by  movable  goitres  in  the  median 
line  of  the  neck  in  young  persons  ;  while  even  small  ones  deeply 
embedded  in  the  lateral  lobes,  or  with  part  of  their  periphery  behind 
the  sternum  or  trachea,  are  not  to  be  removed  without  difliculty  and 
danger.  Even  the  slightest  operation  of  this  kind  must  be  done 
most  carefully,  and  with  skilled  assistants,  unless  the  case  is  very 
urgent  ;  if  there  is  danger  of  suffocation,  of  course  the  tumor  must 
be  removed  or  the  trachea  opened  under  any  circumstances.  Of 
late  I  have  removed  many  hypertrophied  thyroids  and  some  goitres 
with  the  best  results,  healing  usually  taking  place  with  no  complica- 
tions and  no  deaths.     The  most  important  point  in  the  operation  is 


Y52  TUMORS. 

arresting  the  haemorrhage  :  you  should  not  make  a  cut  till  by  press- 
ure-needles or  forceps  you  have  rendered  it  safe  to  divide  the 
parts.  While  the  vessels  entering  or  leaving  the  tumor  have  thus 
been  secured  at  the  periphery,  the  tumor  is  loosened  from  its  at- 
tachments and  removed  ;  do  not  tear  off  adhesions  without  ligating 
them  ;  thick  veins  may  look  like  connective  tissue,  but  bleed  furi- 
ously if  divided.  The  case  is  different  in  removing  single  encapsu- 
lated goitre  nodules  from  the  thyroid  gland  ;  then  by  the  fingers  or 
a  director  the  nodules  may  be  detached  and  turned  out  except  the 
pedicle,  a  firm  cord  containing  the  vessel  which  is  to  be  ligated. 
You  should  never  trust  to  ligating  the  vessels  separately  after  their 
division  ;  too  much  blood  would  be  lost,  and  it  would  take  too  long. 
After  the  operation  apply  an  antiseptic  dressing,  previously  arrang- 
ing the  drainage-tubes  and  sewing  up  the  wound  to  avoid  a  scar  as 
much  as  possible,] 


12.    CYSTS   AND   CYSTOMATA— CYSTIC   TUMORS. 

A  tumor  formed  by  a  sac  filled  with  fluid  or  pulp  is  called  a  cyst 
or  cystic  tumor.  It  may  develop  from  a  sac  already  existing  (cyst), 
or  it  may  develop  entirely  new  (cystoma).  If  the  tumor  be  formed 
of  a  convolution  of  very  many  such  cystic  tumors,  it  is  called  a 
"  composite  cyst  or  cystoma."  If  in  one  of  the  tumors  already  de- 
scribed, or  in  carcinoma,  we  find  cysts  also  forming  an  essential 
part  of  the  tumor,  we  give  them  names  like  cysto-Jihroma,  cysto- 
sarcoma,  cysto-chondroma,  eystu-carcinoma,  etc. 

Vlrchoio  classes  among  tumors  encapsulated  extravasations  (as 
haematoma),  dropsical  effusions,  retention-cysts  (as  hydrops  vesicae 
felleoe),  and  follicular  cysts  (as  in  glands  of  skin). 

Among  the  glands  of  the  cutis,  cysts  develop  from  the  sebaceous 
alone  ;  I  do  not  know  that  cysts  of  the  perspiratory  glands  have  ever 
been  described.  The  reasons  for  secretion  collecting  in  the  sebaceous 
glands  are  :  (a)  its  becoming  inspissated ;  {b)  closure  of  the  excretory 
duct.  If  from  either  of  these  causes  the  secretion  be  retained  and 
collect  in  the  gland,  the  pouched  secreting  surface  becomes  expanded 
to  a  simple  sphere ;  the  collected  secretion  exercises  a  mechanical 
irritation  on  the  surrounding  connective  tissue,  which  consequently 
becomes  thickened  and  surrounds  the  secretion  like  a  vesicle.  If  the 
sac,  not  yet  grown  large,  can  be  evacuated  by  strong  pressure,  the 
small  open  cyst  is  called  a  comedo,ov  "maggot."  If,  from  any  irrita- 
tive inflammatory  process,  the  excretory  duct  of  a  sebaceous  gland  be 
closed,  there  may  be  atrophy  of  the  gland,  as  after  a  burn  with  verv 


CYSTOMATA  753 

superficial  destruction  of  the  skin  ;  but  in  other  cases  the  secretion  of 
the  gland  continues,  and  it  distends  slowly  to  a  large  sac.  Such  cysts, 
filled  with  fatty  pulp  and  epidermis,  are  called  pap-bags  {grutzbeutel), 
atheromata.  On  microscopic  examination  we  find  the  pulp  to  consist 
of  fat-drops,  fat-crystals,  especially  cholestearine,  epidermis-cells,  and 
small  plates.  It  has  very  varied  color  and  consistence  ;  most  athero- 
mata on  the  scalp,  which  develop  at  advanced  age,  contain  a  dirty- 
grayish  brown,  badly-smelling,  pulpy,  pasty,  sticky  substance.  Other 
tumors  of  this  sort,  especially  those  that  are  congenital,  on  the  fore- 
head, temples,  or  face,  are  filled  with  a  milky  or  light-yellow  pulp, 
which,  under  the  microscope,  shows  little  besides  epidermis-scales 
and  crystals  of  cholestearine.  This  form  of  atheroma  is  called  "  chole- 
steatoma." The  sacs  of  these  cysts  are  usually  thin,  and  are  com- 
posed of  connective  tissue ;  their  inner  surface  is  usually  distinctly 
bounded  by  rete  Malpighii,  and  is  wavy,  or  elevated  into  papilloa.  I 
have  found  no  other  resemblance  to  cutis  in  these  sacs,  but  others 
have  found  hairs  and  sweat-glands  in  them.  The  contents  of  these 
cysts  sometimes  become  calcareous.  Atheroma  may  rupture  as  a 
result  of  injury,  or,  very  rarely,  spontaneously  ;  the  pulp  is  evacuated, 
the  edges  of  the  opening  are  everted,  and  the  inner  surface  of  the  sac 
becomes  a  bad-looking,  ulcerated  surface ;  except  on  the  head  and  face, 
where  they  are  frequent,  these  tumors  rarely  occui-. 

In  the  neck,  salivary  ducts  (closed  internally  and  externally,  but 
open  in  the  middle,  which  are  lined  with  epidermis)  may,  in  the  course 
of  years,  become  large  cholesteatomata  by  the  deposit  of  epidermis. 
These  show  themselves  in  the  mouth  (as  ranula),  or  externally  on  the 
neck  above  and  behind  the  thyroid. 

In  the  mucous  membranes,  also,  inspissation  of  the  glandular  mucus 
and  consequent  hinderance  to  its  evacuation,  may  cause  development 
of  mucous  cysts ;  but  j^robably  the  more  frequent  cause  of  retention- 
cysts  here  is  closure  of  the  excretory  duct.  The  secretion  in  these 
glands  is  usually  a  tenacious,  often  thick  mucus,  of  a  honey-color  (me- 
liceris),  reddish  yellow,  or  even  chocolate-brown.  On  microscopical 
examination  of  the  contents  of  the  cyst,  we  find  numerous  large,  pale, 
round  cells,  often  containing  fat-globules,  in  homogeneous  mucus,  also 
cholesterine  crystals,  often  in  large  quantities.  In  the  nasal  mucous 
membrane  these  c^ysts  are  rare,  but  they  occur  in  nasal  mucous  polypi, 
often  to  such  an  extent  as  to  give  them  the  name  of  cystic  polypi. 
LuschJca  often  found  small  cysts  in  the  mucous  membrane  of  the 
antrum  Highmori.  In  the  oral  mucous  memlirane  they  occur  chiefly 
on  the  inside  of  the  lips,  more  rarely  on  the  cheeks  ;  they  arc  an  ordi- 
nary occurrence  in  the  uterine  mucous  membrane  and  in  uterine 
polypi.  In  the  rectal  mucous  membrane,  on  the  contrary,  mucous 
49 


754  TUMORS. 

cysts  do  not  occur,  and  they  are  very  rare  in  tlie  mucous  membranes 
deep  in  the  body. 

Neoplastic  cystfi.  These  resiilt  mostly  from  softening  of  tissue 
previously  diseased  by  cell-infiltration,  or  of  firm  tumor-substance. 
As  soon  as  the  new  formation  has  separated  into  sac  and  fluid  con- 
tents, in  some  cases  a  secretion  from  the  inner  -wall  of  the  sac  begins, 
so  that  the  softening  cyst  becomes  a  secretion  or  exudation  cyst,  and 
thus  grows.  Any  tissue  rich  in  cells  may  be  transformed  into  a  cyst 
by  mucous  metamorphosis  of  the  protoplasm,  or,  as  others  express  it, 
by  separation  of  the  mucous  substance  through  cells,  without  any 
connection  \A'ith  development  of  mucous  glands.  In  the  foetus,  we 
know  there  is  a  development  of  cavities  (i.  e.,  the  joints)  by  mucous 
softening  of  the  cartilage-tissue.  In  cartilage-tissue  there  is  often  a 
mucous  softening  of  certain  parts,  by  which  chondromata  with  mucous 
cysts  are  developed.  In  the  same  way  it  is  not  uncommon  for  parts 
to  become  fluid  and  encapsulated  ;  the  same  thing  occurs  in  sarcoma, 
especially  in  giant-celled  sarcoma.  The  often  slit-shaped,  smooth- 
walled  cysts,  with  serous  or  sero-mucous  contents  which  occur  in 
uterine  myomata,  are  possibly  enormously  dilated  lymph-spaces. 
Bone-cysts  always  originate  by  softening ;  the  often  glistening 
smooth  membrane  lining  such  cysts  may  in  the  course  of  time 
actually  secrete. 

While  the  above  varieties  of  neoplastic  cysts  have  no  relation  to 
gland  new  formations,  those  we  are  now  about  to  mention  develop 
from  adenoma.  The  cysts  of  the  thyroid,  cystic  goitre,  already  men- 
tioned (page  749),  have  a  somewhat  uncertain  position  in  this  series ; 
uncertain  because  they  are  not  due  to  newly-formed  gland  follicles  or 
ducts,  but  to  collection  of  mucous  secretion  in  one  of  the  thyroid  vesi- 
cles. If  we  term  the  contents  of  these  cysts  secretion,  as  we  might  do 
for  some  reasons,  we  must  class  these  cysts  as  retention-cysts.  But,  as 
it  might  be  urged  on  the  other  hand  that  it  would  be  questionable  to 
speak  of  a  secretion  of  the  thj-roid  gland,  as  some  state  that  normally 
the  contents  of  the  thyroid  vesicles  consist  solely  of  cells,  we  may  also 
consider  the  c^'sts  resulting  from  softening  of  the  contents  of  the  vesi- 
cles as  newly  formed.  Whichever  view  we  take,  it  is  certain  that  the 
cysts  of  the  thyroid  may  be  solitary,  and  may  attain  great  size.  More- 
over, in  almost  every  large,  and  in  some  small,  otherwise  firm  goitres, 
one  or  more  cysts  occur;  they  usually  have  very  smooth  walls.  The 
large,  isolated  cysts  of  this  variety,  particularly,  give  the  impression 
that  they  are  chiefly  secretion-cysts,  while  other  similar  cavities  in 
other  parts  of  large  goitres,  by  their  softened,  ragged  walls,  give  the 
impression  of  being  softening  cysts.  In  the  thyroid  gland  the  process 
of  softening  usually  terminates  in  the  formation  of  a  mucous  fluid* 


CYSTOMA!  A.  755 

but  there  are  other  cysts  in  these  glands  that  contain  a  giay,  friable 
pulp,  which  looks  like  that  from  sebaceous  glands,  but  differs  essen- 
tially from  it  because  it  contains  only  the  detritus  of  thyroid  tissue  ; 
I  have  never  seen  genuine  atheroma-pulp  in  thyroid  cysts. 

Among  the  complicated  cystic  tumors  are  the  cysto-sarcomata  of 
the  breast,  of  which  we  have  already  spoken  (page  731),  cystoraata 
of  the  ovary  and  testicle,  cj^sto-adenoma,  cysto-sarcoma,  and  cysto- 
carcinoma.  According  to  recent  investigations,  in  the  great  majority 
of  these  cases  there  is  a  new  development  of  gland  follicles  or  ducts, 
from  which  terminal  swellings  become  choked  off,  as  results  normally 
HI  the  development  of  thyroid  or  ovarian  follicles.  A  mucous  wine- 
yellow,  brownish-red,  or  dark-brown  fluid  is  secreted  in  these  newly- 
formed  follicles  (perhaps  also  in  the  normal  ovarian  follicles)  ;  this 
gradually  distends  the  follicle,  which  was  at  first  microscopic.  Some- 
times immense  ovarian  tumors  (distending  the  abdomen  more  than  it 
is  in  the  ninth  month  of  pregnancy)  may  develop  from  such  a  follicle, 
or  from  the  confluence  of  several  of  them  to  a  common  cavity.  In 
other  cases,  himdreds  or  thousands  of  such  follicles  develop,  forming 
the  multilocular  cystic  tumors  of  the  ovary.  The  latter  jDrocess  also 
occurs  in  the  testicle,  although  more  rarely  than  in  the  ovary.  In 
both  of  these  organs,  as  in  the  mamma  and  thyroid,  the  contents  are 
mucous  as  a  rule ;  but,  in  the  neoplastic  follicular  cysts  of  the  ovary 
and  testicles,  there  are  occasionally  secretion  of  fat  and  extensive  pro- 
duction of  epidermis ;  these  may  remain  as  epithelial  or  epidermis 
pearls  (cholesteatoma  pearls,  page  753),  as  big  as  a  millet-seed  or  a 
pea,  as  I  have  seen  them  in  tumors  of  the  testicle,  or  form  large  cysts 
containing  fat-pulp.  The  walls  of  these  cysts,  which  are  found  the 
size  of  a  child's  head  or  larger,  in  the  ovaries  of  old  women,  are  usually 
more  highly  organized  than  those  of  cutis  atheroma  ;  large  quantities 
of  hair,  sebaceous  glands,  sweat-glands,  papillae,  even  warty  growths, 
are  not  unfrequently  found  in  them.  Indeed,  plates  of  caitilage  and 
bone,  with  teeth  of  varied  form,  have  been  found  in  these  cysts,  so  as 
to  render  it  probable  that  they  were  aborted  foetuses  from  an  incom- 
plete ovarian  pregnancy. 

Besides  occurring  at  the  above  positions,  composite  cysts  are  occa- 
sionally congenital  about  the  sacrum  ;  they  often  contain  ciliated  epi- 
thelium, and,  besides  other  tissues,  they  sometimes  have  glandular, 
follicular  formations.  The  tissues  in  these  congenital  tumores  coc- 
cygei  vary  from  the  relatively  simple  forms  of  c}-sto-sarcoma  to  the 
foetus  infoetu,  and  cannot  here  be  fruther  entered  into  without  going 
into  details  and  fine  discussion. 

I  must  lastly  mention  cysts  containing  perfectly  fluid  venous 
blood,  and  having  smooth  walls,  which  are  here  and  there  mentioned 


756 


TUMORS. 


in  literature.  Some  of  them  refill  rapidly,  others  more  slowly,  after 
puncture ;  such  cysts  have  been  observed  in  the  axilla,  on  the  thorax 
and  neck.  Excluding  those  cases  where  effusions  of  blood  have  given 
a  dark  blood-color  to  the  mucous  of  serous  contents  of  a  cyst,  and 
considering  only  those  in  which  there  is  blood  alone  in  the  cysts, 
they  could  scarcely  have  been  any  thing  but  large  sacs  on  the  veins 
or  cavernous-venous  tumors  whose  framework  had  been  entirely 
atrophied.  All  the  cases  of  this  kind  so  far  reported  have  been 
cured  by  puncture  and  injection  with  iodine,  so  that  nothing  can  be 
said  of  the  pathological  anatomy. 

The  diaf/nosis  of  cystic  tumor  is  easy ;  if  it  can  be  certainly  pal- 
pated, the  fluctuation  will  be  felt ;  deeply-seated  cysts  are  often  diffi- 
cult to  recognize.  They  may  be  mistaken  for  other  encapsulated 
fluids ;  an  exploratory  puncture  with  a  very  fine  trocar  is  admissible 
to  confirm  the  diagnosis,  if  this  be  necessary  to  determine  the  treat- 
ment. There  are  various  things  for  which  a  cyst  may  be  mistaken  ; 
e.  g.,  cold  abscesses  are  also  painless,  occasionally  very  slowly  enlar- 
ging, fluctuating  tumors  ;  also  cystic  parasites,  of  which  two  varieties 
occur  in  the  outer  ])arts  of  the  body,  especially  in  the  subcutaneous 
tissue ;  cysticerciis  cellulosce  and  echijiococcus  hominis,  although  rare,  do 
occur  in  the  cellular  tissue  (and  still  more  rarely  in  bone) ;  the  former 
is  a  small,  the  latter  a  large  vesicle,  which  may  contain  many  smaller 
ones ;  the  vesicle  of  which  the  animal  consists  aUvays  has  a  neo- 
plastic sac  around  it ;  as  may  be  readily  seen,  the  whole  thing  gives 
the  impression  of  a  cystic  tumor.  I  have  seen  C3'sticercus  vesicles 
removed  from  the  tongue  and  nose,  echinococcus  vesicles  removed  from 
the  back  and  thigh.  The  diagnosis  of  cysts  was  made  in  all  the 
cases  except  in  one  of  the  latter  where  abscess  was  diagnosed,  and  in 
fact,  instead  of  the  customary  encapsulation,  there  was  suppuration 
around  the  dead  echinococcus  vesicle.  I  have  introduced  this  as  a 
sort  of  appendix,  because  we  have  nowhere  else  an  opportunity  of 
considering  the  parasites.  The  millions  of  trichince  occasionally 
scattered  through  the  muscles  cannot  be  treated  surgically,  even 
when,  according  to  the  brilliant  investigations  of  Zenker^  the  diagno- 
sis may  be,  and  has  been,  made  in  many  cases.  Dropsies  of  the  sul> 
cutaneous-mucous  bursas  and  of  the  tendinous  sheaths  as  well  as  spina 
bifida  may  also  be  readily  mistaken  for  cystic  tumors,  if  we  do  not 
attend  to  the  anatomical  seat  of  these  swellings.  Cystomata  may  also 
be  mistaken  for  other  gelatinous  soft  sarcomata  and  carcinomata,  and 
for  very  soft  fatty  tumors.  As  stated,  when  an  intention  of  oper- 
ating renders  a  certain  diagnosis  necessary,  we  make  an  exploratory 
puncture.  But  what  guides  us  chiefly,  in  the  diagnosis,  is  the  expe- 
rience about  the  relative  frequence  of  different  tumors  on  different 


(TYSTOMATA.  757 

parts  of  the  body ;  I  have  given  you  the  sum  of  these  experiences  in 
each  form  of  cyst,  and  in  the  clinic  shall  hereafter  direct  your  special 
attention  to  this  point. 

As  the  above  includes  the  prognosis  of  cystic  tumors,  all  of  which 
grow  slowly  when  they  exist  as  cysts  without  complication,  we  may 
pass  at  once  to  then-  treatment.  We  may  remove  cysts  in  two  ways, 
viz. :  by  evacuating  the  contents,  and  locally  applying  remedies  that 
may  excite  an  inflammation  which  shall  cause  atrophy  of  the  sac,  or 
by  extirpating  the  sac ;  the  latter  is  always  the  simplest  and  most 
rapid,  and  we  always  give  it  the  preference  where  it  can  be  done 
easily  and  without  danger  to  life.  But  in  cysts  of  the  ovary,  thyroid, 
and  other  glands,  that  are  deeply  seated  or  from  other  causes  danger- 
ous, some  other,  safer  operation  is  of  course  desirable,  if  it  offers  a 
prospect  of  success.  We  may  induce  shrinkage  of  the  sac  after  pre- 
cedent evacuation  of  the  contents,  by  a  suppurative  or  by  a  milder, 
drier  inflammation.  If  you  sht  up  the  wall  of  the  cyst  its  whole 
length,  and  keep  the  cut  edges  apart,  there  will  be  suppuration  and 
granulation  of  the  exposed  inner  wall  of  the  cyst,  with  detachment 
of  the  portions  of  tumor  or  epithelium  clinging  to  it ;  the  sac  then 
gradually  shrinks  up  into  a  cicatrix,  then  decreases  in  size,  and  finally 
heals ;  but  this  may  require  months.  You  may  attain  the  same  thing 
in  a  more  subcutaneous  way,  by  ligatures  or  tubes  tlu-ough  the 
tumor  at  different  points ;  the  irritation  caused  by  these,  as  well  as 
by  the  entrance  of  air,  causes  suppuration  and  granulation  of  the 
inner  w^all,  and  in  favorable  cases  these  may  lead  to  atrophy ;  often 
this  does  not  occur  in  the  manner  desired,  or  else  it  may  require 
months  or  years ;  so  that  of  these  two  methods  the  first  is  preferable ; 
it  is  particularly  applicable  to  cysts  of  the  neck.  We  may  attain 
shrinkage  of  the  cyst  and  drying  up  of  its  contents  in  another  way, 
namely,  by  puncture,  with  subsequent  injection  of  tincture  of  iodine ; 
we  have  already  (page  579)  said  enough  about  the  effect  of  this  treat- 
ment. Here,  too,  the  injection  is  followed  by  severe  inflammation  of 
the  sac  w4th  sero-fibrinous  exudation ;  then  the  serum  is  reabsorbed 
and  the  sac  contracts.  The  latter  method  is  particularly  applicable 
when  we  have  to  deal  not  with  contents  of  softened  tissue,  but  with 
a  fluid  secreted  by  tlie  walls  of  the  sac,  that  is,  chiefly  with  cysts 
whose  contents  are  serous,  and  some  sorts  of  mucous  cysts.  Cysto 
mata  developed  from  softened  gelatinous  substance  and  fat-cysts  are 
not  suited  for  iodine  injections ;  for  they  are  apt  to  be  followed  by 
severe  inflammation  and  suppuration,  with  formation  of  gas,  so  that 
we  are  subsequently  obliged  to  slit  up  the  entire  sac.  And  very  thick 
walls,  which  contract  very  slowly  or  not  at  all,  also  contraindicatc 
iodine  injections.     Hence  among  cysts  of  the  neck  we  find  some  thai 


758  TUMORS. 

are  suited  for  this  treatment,  others  which  are  not,  because  their  walls 
ai'e  too  thick.  Of  the  ovarian  cysts,  too,  unfortunately  but  few  are 
suited  for  treatment  by  iodine  injection,  so  that  recently  the  extirpa- 
tion of  these  tumors  by  laparotomy  is  considered  the  only  certain 
operative  proceeding  ;  of  late  years  the  results  from  this  operation 
have  constantly  been-  growing  more  favorable.  Lastly,  we  must  state 
that  in  some  cases  it  is  best  to  avoid  any  operation;  for  instance,  I 
should  consider  it  folly  to  persuade  an  old  man,  with  a  number  of 
atheromata  on  his  head,  to  have  tliem  removed ;  for,  if  the  operation 
were  followed  by  erysipelas,  it  might  prove  fatal. 


LECTURE    L. 

18.  Carcinomata. — Historical  Remarks. — General  Description  of  the  Anatomical  Struct- 
ure.— Metamorphoses. — Forms. — Topogrraphy. —  1.  Skin  and  Mucous  Membranes 
with  Pavement  Epitlielium. — 2.  Milk  Glands. — 3.  Mucous  Glands  with  Cylindrical 
Epithelium. — i.  Lachrymal  Glands,  Salivary  Glands,  and  Prostate  Glands. — 5. 
Thyroid  Glands  and  Ovaries. — Treatment. — Brief  Remarks  about  the  Diagnosis. 

13.  CARCINOMATA--CAXCEROUS  TUMORS. 

To  give  you  an  idea  of  how  tumors  were  formerly  diagnosed,  and 
of  the  origin  of  many  of  the  names  still  in  use,  I  will  read  you  a  pas- 
sage from  the  classical,  and,  in  its  time,  most  prominent,  work  of 
Lorenz  Heister,  the  third  edition  of  which,  published  in  1731,  I  have 
before  me.  Here  (page  230)  it  saj-s  :  "  The  name  scirrhiis  is  given 
to  a  painless  tumor  that  occurs  in  all  parts  of  the  body,  but  especially 
in  the  glands,  and  is  due  to  stagnation  and  drying  of  the  blood  in 
the  hardened  part."  (Page  318)  "  When  a  scirrhus  is  not  reabsorbed, 
cannot  be  arrested,  or  is  not  removed  by  time,  it  either  spontaneously 
or  from  maltreatment  becomes  malignant,  tliat  is,  painful  and  in- 
flamed, and  then  we  begin  to  call  it  cancer  or  carcinoma  /  at  the 
same  time  the  veins  swell  up  and  distend  like  the  feet  of  a  crab  (but 
this  does  not  happen  in  all  cases),  whence  the  disease  gets  its  name  ; 
it  is,  in  fact,  one  of  the  worst,  most  horrible,  and  most  painful  of  dis- 
eases. While  the  skin  remains  intact  over  it,  it  is  termed  A ?(?(/e;i  (can- 
cer occultus),  but,  when  the  skin  has  opened  or  ulcerated,  it  is  called 
open^  or  ulcerated  cancer  ;  the  latter  usually  succeeds  the  former." 

It  is  not  long  since  men  lived  in  the  simjile  belief  that  there  was 
something  real  and  truly  practical  in  this  mode  of  comparison  and 
description.  In  a  hundred  years  will  they  laugh  at  our  present  ana- 
tomical and  clinical  definitions,  as  we  now  do  at  good  old  Heister  ? 
V\nio  knows  ?     Time  moves  on  with  giant  strides ;  things  come  to 


CYSTOMATA,  CARCINOMATA.  759 

light,  and,  before  we  have  time  to  look  around,  they  are  turned  into 
history  by  the  careful  labors  of  energetic  young  experimenters. 

In  the  natural  sciences  we  always  dislike  to  give  short  definitions, 
because  this  is  often  impossible,  on  account  of  the  passage  of  one  pro- 
cess, or  of  one  formation,  into  another.  We  may  say  that  carcino- 
mata  are  very  infectious  tiunors,  and  that  this  infection,  which  first 
attacks  the  lymphatic  glands,  afterward  more  distant  organs,  is  prob- 
ably due  to  the  passage  of  elements  from  the  tumor  (whether  of  cells 
or  juice  is  not  3'et  kno^vn)  through  the  lymphatic  vessels  and  veins 
into  the  blood. 

This  common  clinical  definition  of  carcinoma  should  be  controlled 
by  the  anatomical  structure  of  these  tumors.  Anatomical  peculiari- 
ties, easily  recognized  with  the  naked  eye  or  with  the  microscope,  are 
sought  for.  The  classical  monographs  of  Astley  Cooper  on  diseases 
of  the  testis  and  breast  (the  latter,  unfortunately,  unfinished)  show 
that,  by  a  careful  study  of  the  points  perceptible  to  the  naked  eye,  a 
great  deal  may  be  attained  by  studying  a  single  organ ;  but  a  general- 
ization by  aid  of  the  anatomical  preparations  alone  is  impossible,  as  we 
have  often  felt,  in  the  course  of  these  lectures — it  is  frequently  difficult, 
even  with  our  present  aids ;  so  that  I  cannot  blame  Virchow  for  try- 
ing, in  his  great  work  on  tumors,  to  give  most  minute  descriptions  of 
the  different  forms  of  tumors  at  certain  localities.  Here,  where  we 
must  express  ourselves  briefly,  to  give  our  descriptions  an  anatomical 
basis,  we  must  be  somewhat  more  decided  and  summar3\  "When  the 
naked  eye  no  longer  sufficed  for  the  diagnosis  of  tumors,  the  aid  of 
the  microscope  was  invoked,  and  characteristic  appearances  were 
sought  that  might  occur  in  the  same  way  in  all  the  tumors  we  have 
described.  Still,  whether  the  characteristics  of  the  cellular  elements 
were  sought  in  their  processes,  the  size  of  the  nucleus  or  of  the  nucle- 
olus, the  clinical  and  anatomical  peculiarities  would  not  always  remain 
congruous.  ^^Tien  the  cells  proved  inefficacious  as  emlence  of  carci- 
noma, it  was  sought  for  in  the  general  structure  of  the  tumor ;  alveo- 
lar formation  was  asserted  to  be  the  anatomical  peculiarity.  We 
even  come  in  collision  with  this  idea  occasionally ;  the  net-like  forma- 
tion of  neoplastic  lymphatic  gland-tissue  may  also  be  termed  "  alveo- 
lar," and  even  acknowledging  that  the  lymphoma  net- work  is  so  pecu- 
liarly characterized  by  its  form  that  it  may  be  readily  excluded,  there 
still  remain  some  forms  of  chondromata  and  sarcomata,  especially  the 
giant-celled,  and  other  large-celled  sarcomata  forms,  which  we  have 
already  designated  as  alveolar  sarcomata  (pages  717  and  720),  as  the 
ghosts  of  cancer. 

Since  anatomical  study,  especially  the  origin  of  neoplasms,  has 
been  regarded  as  an  essential  principle  of  division,  we  escape  all  the 


760  TUMORS. 

difficulties  just  enumerated.  Now,  anatomy  alone  decides  what  is  to 
be  called  cancer.  In  the  clinic  we  then  have  to  investigate  how  can- 
cers of  different  formations  and  compositions  usually  conduct  them- 
selves :  if  they  be  infectious  or  not ;  whether  they  run  their  course 
slowly  or  rapidly ;  if  they  are  usually  solitary  or  multiple ;  where 
most  frequent,  and  how  they  are  most  successfully  treated.  Most 
modern  pathologists  agree  in  calling  only  those  tumors  true  carci- 
nomata  which  have  a  formation  similar  to  that  of  true  epithelial 
glands  (not  the  lymphatic  glands),  and  whose  cells  are  mostly  actual 
derivatives  from  true  epithelium.  I  am  convinced  that  this  view  will 
constantly  have  more  adherents,  and  that  thus  the  differences  about 
the  anatomical  definition  of  "  carcinoma "  will  constantly  diminish. 
Those  investigators  who,  during  the  last  few  years,  with  all  the  mod- 
ern aids,  have  worked  without  prejudice  on  this  portion  of  the  study 
of  tumors,  recognize  the  great  importance  of  epithelial  proliferation 
in  those  tumors  that  we  call  cancer,  still  most  of  them  seek  for  a 
compromise  between  the  different  histogenetic  views,  and  wish  still 
to  admit,  in  a  modified  form,  the  development  of  true  glandular  and 
epithelial  cells  from  connective  tissue  (heterology  proper)  [Hind' 
fleisch,  Volk/nann,  Klebs,  Lixclce)  ;  cnl}'  Thiersch,  and  recently  Wal- 
deyer,  maintain,  as  I  do,  the  strict  boundary  between  epithelial  and 
connective-tissue  cells.  Waldeyer  defines  carcinoma  as  an  atypical 
epithelial  neoplasm.  But  we  must  here  state  that  in  cancer-tumors, 
besides  the  e{)itlieliums,  there  are  usuallj'  numerous  young,  small  round 
cells  which,  infiltrated  in  the  connective-tissue  portion  of  the  tumor, 
form  an  important  part  of  it.  This  small-celled  connective-tissue  in- 
filtration, which  exists  in  varying  quantities  wherever  epithelial  pro- 
liferations grow  into  the  tissue,  appears  to  be  caused  by  a  sort  of  re- 
action, and  to  be  the  result  of  the  penetration  of  the  epithelial  new 
formations  into  the  tissue,  according  to  the  number  of  infiltrated  cells 
and  their  future  fate,  as  well  as  the  degree  of  vascularity,  just  as  in 
inflammation  it  sometimes  leads  to  softening,  to  atroph}^,  and  cicatri- 
cial thickening  of  the  tissue.  In  some  cases  this  small-celled  infiltra- 
tion is  so  considerable  as  almost  entirely  to  hide  the  epithelial  new 
formation  (from  which  it  may  be  very  difficult  to  distinguish,  if  the 
latter  be  small).  We  may  then  be  in  doubt  if  it  should  not  be  re- 
garded as  entirely  independent,  and  occasionally,  perhaps,  as  the  sole 
constituent  of  cancerous  tumors.  Formerly  I  myself  thought  it  neces- 
sary to  agree  to  this,  and  even  supposed  that  this  component  of  car- 
cinoma possessed  a  spontaneous  power  of  infection  ;  but  further  ob- 
servations with  new  aids  have  made  it  appear  to  me  more  probable 
that,  even  in  the  smallest  cancerous  nodules,  epithelial  elements  are 
proliferating.     The  epithelial  cells,  and  the  base  on  which  they  grow 


CARCINOMATA. 


761 


and  from  which  they  draw  their  nourishment,  are  most  intimately 
connected.  Many  observations  show  certainly  that  the  cellular  infil- 
tration of  the  connective-tissue  base  causes  an  increased  proliferation 
of  the  superjacent  epithelium ;  so  it  would  not  be  difficult  to  suppose 
that  the  first  impulse  to  the  atypic  adenoid  proliferation  was  due  to 
an  irritative  state  of  the  epithelial  base.  But  it  is  just  as  possible 
and  probable  that  the  epithehal  proliferation  is,  as  we  usually  con- 
sider it,  the  first  formative  process  in  the  development  of  carcinoma. 
There  can  be  no  direct  observation  on  this  point;  the  connective- 
tissue  infiltration  is  always  there  as  soon  as  the  epithelial  prolifera- 
tion ;  this  so  much  impedes  investigation  of  the  first  stage,  that  a 
choice  of  verj^  favorable  objects  (such  as  flat  cancer  of  the  skin)  alone 
will  give  any  evidence  in  favor  of  our  view,  while  the  study  of  more 
difficult  objects  (as  infiltrated  lymphatic  glands)  in  which,  during 
life,  the  most  varied  cells  are  mixed  up,  will  find  plenty  of  support 
for  Yirchow's  view  (which  I  formerly  held),  according  to  which  epi- 
thelial cells  may  result  from  proliferation  of  connective-tissue  cells. 

It  is  especially  important,  anatomically,  to  make  a  distinction  be- 
tween adenoma  and  carcinoma,  as  the  two  forms  of  tumors  have  some 
points  in  common.  Pure  adenomata  are  composed  of  newly-formed 
gland-substance  which  is  entirely  analogous  to  or  at  least  very  much 
like  the  normal ;  the  connective  tissue  around  the  newly-formed  acini 
bas  the  same  relation  to  them  as  to  the  normal. 

In  adeno-sarcoma  there  is  little  if  any  new  formation  of  glandular 
acini,  but  the  sarcoma  merely  encloses  the  glandular  spaces  which 
have  remained  normal,  or  are  dilated.  But  it  is  characteristic  of  car- 
cinoma that  the  epithelial  covering  of  a  skin  or  mucous  membrane,  or 
the  epithelial  lining  of  glandular  cavities,  grows  into  the  skin,  and 
even  deeper,  in  the  form  of  roundish  nodules  (acinous),  or  of  round 
cylinders  or  rollers  (tubular),  just  as  occurs  in  the  foetus.  While  so 
doing,  the  epithelial  cells  usually  preserve  their  form,  only  they  often 
grow-  much  larger  than  normal.  The  form  of  the  glands  from  which 
these  formations  proceed  generally  remains  ty]Dical  for  the  neoplasm 
also ;  but  it  remains  in  irregular  forms  of  glands,  it  is  only  rarely  that 
cavities  are  formed,  and  that  actual  secretion  goes  on  in  these  cavities. 
Besides  the  epithelial  parts  of  these  tumors,  the  connective  tissue, 
bones,  muscles,  etc.,  into  which  the  epithelium  enters,  conduct  them- 
selves as  follows :  We  sometimes  find  them  of  normal,  again  of  abnor- 
mal firmness,  sometimes  very  soft,  almost  mucous,  ordinarily  in  less 
quantity  than  the  epithelial  masses.  It  is  usually  pervaded  by  small, 
round  (lymph)  cells,  often  to  such  an  extent  that  scarcely  any  fibroug 
tissue  is  left ;  generally  the  infiltrated  small  cellular  elements  are  scat^ 
tered  diflFusely  in  the  cancerous  (connective-tissue)  framework;  very 


702 


TUMORS. 


rarely,  we  find  numerous  cells,  collected  together  in  a  fissure  betwe(!n 
the  connective-tissue  bundles.  When  the  tumor  advances  into  the 
bone,  the  latter  is  eaten  away,  as  in  caries.  I  have  not  been  able  to 
satisfy  myself  that  there  is  any  new  formation  of  connective-tissue 
filaments  in  the  nodular  and  infiltrated  forms  of  these  tumors,  nor  have 
I  been  able  to  find  any  osseous  new  formation ;  but  there  is  no  doubt 
that  such  a  new  formation  occurs  in  the  papillary  and  villous  forms, 
of  which  we  shall  hereafter  speak.  From  this  description  you  see 
that  Waldeyer's  expression  about  the  epithelial  formation  in  carcinoma 
hemg  aty2ncal  {tissu  heteroadenique  of  Itohin)is  also  well  suited  for 
distinguishing  carcinomata  from  adenomata,  as  typical  new  formations. 

As  regards  the  vessels  in  these  tumors,  we  may  satisfy  ourselves, 
by  artificial  injections,  that  the  dilatation  and  new  formation,  by  tor- 
tuosity and  looping,  are  considerable ;  only  the  connective-tissue  por- 
tions of  the  tumor  are  vascularized,  the  epithelial  portions  remain  free  ; 
this  is  a  very  important  anatomical  criterion,  as  is  the  fact  that  true 
epithelial  cancer-cells  never  unite  together  as  the  large  epithelio- 
cells  of  some  sarcomata  do ;  Waldeyer  has  justly  attached  great  im- 
portance to  this  latter  point.  I  cannot  go  any  further  into  the  gen- 
eral histological  description  of  these  tumors,  and  hope  that  they  may 
be  recognizable  from  the  above,  although  I  acknowledge  that  it  is 
sometimes  very  difficult  to  distinguish  carcinoma  from  adeno-sarcoma 
and  alveolar  sarcoma. 

According  to  my  whole  histogenetic  view,  I  must  regard  it  as  im- 
possible for  an  epithelial  cancer  to  occur  primarily  in  a  bone  or  lym- 
phatic gland.  The  observations  that  I  know,  to  this  effect  (in  the 
lower  jaw,  on  the  anterior  surface  of  the  tibia,  in  the  lymphatic  glands 
of  the  neck),  do  not  seem  to  me  sufficient  proof,  because  the  skin  and 
mucous  membrane  are  so  near;  there  j?iay  have  been  an  insignificant 
carcinomatous  disease  of  the  skin  or  mucous  membrane  as  a  starting- 
point  of  the  disease,  without  its  haWng  been  noticed. 

The  appearance  of  the  cut  surface  of  this  tumor,  and  its  consist- 
ence, vary  so,  that  no  general  description  can  be  given  of  it. 

In  the  great  majority  of  cases,  carcinoma  appears  in  the  form  of 
nodules ;  also  as  indurations  of  otherwise  soft  tissues,  or  as  papillary 
proliferations.  Rarely,  the  diseased  parts  are  separated  from  the 
healthy  tissue  by  a  connective-tissue  capsule ;  but,  in  most  cases,  the 
passage  from  healthy  to  diseased  tissue  is  more  gradual.  In  some 
cases  there  is  no  cancerous  tumor,  but  a  cancerous  infiltration,  there 
being  no  enlargement,  possibly  even  a  diminution  in  size  of  the 
affected  organ.  It  is  also  characteristic  of  carcinoma  that  part  of  the 
new  formation  is  very  short-lived,  disintegrates  directly  or  after  pre- 
cedent  fatty  degeneration    is   reabsorbed,  and   then  the  infiltrated 


CARCINOMATA.  763 

fibrous  tissue  contracts  to  a  firm  cicatrix.  Besides  this  cicatri(.'ial 
shrinking,  and  not  unfrequently  along  with  it,  there  is  often  softening  ; 
it  is,  perhajDS,  even  more  frequent  than  contraction ;  at  all  events,  it  is 
more  extensive.  This  softening  is  mostly  preceded  by  fatty  degen- 
eration of  the  cells  and  caseous  metamorphosis;  central  softcnino-, 
opening  outwardly,  formation  of  a  putrid  ulcer,  with  fungous  edges,  is 
very  characteristic  of  carcinoma.  Mucous  metamorphosis  of  the  cell- 
protoplasm  also  takes  place  in  some  glandular  carcinomata,  relatively 
most  often  in  those  of  the  liver,  stomach,  and  rectum ;  in  rare  cases, 
this  also  affects  the  connective-tissue  stroma.  This  mucous  cancer  is 
also  called  gelatinous  or  colloid.  When  cancerous  degenerations  oc- 
cur on  the  surface,  the  papillary  layer  may  develop  so  as  to  become 
very  prominent,  as  in  some  pa2)illary  cancers  (destructive  papillomata) 
of  the  mucous  membrane  of  the  lips,  stomach,  and  portio  vaginalis, 
and  as  in  villous  cancer^  w^iich  develops  on  the  mucous  membrane  of 
the  bladder,  in  the  form  of  dendritic,  branched,  large  papillae.  If  the 
cicatricial  contraction  predominate  in  a  carcinoma  (as  it  does  in  some 
forms  of  cancer  of  the  breast),  hard  tumors  or  ulcers  are  developed, 
which  have  for  ages  been  called  scirrhus.  Some  carcinomata  are 
brown  or  black,  but  still  melano-carcinomata  are  rare.  Most  soft 
melanomata  are  sarcomata. 

[Before  true  infection  occurs  in  the  lymphatic  glands  they  are 
temporarily  swollen  by  inflammation.  This  is  shown,  among  other 
things,  by  the  fact  that  after  removal  of  some  carcinomata  there  is 
complete  and  permanent  recovery,  although  at  the  time  of  the  oper- 
ation enlarged  lymphatic  glands  in  the  neighborhood  were  not  re- 
moved. The  glands  form  a  barrier  to  protect  the  organism  against 
infection  ;  but  in  some  cases  the  barrier  is  broken  through,  and  me- 
tastatic tumors  occur  in  internal  organs  and  in  the  bones.  In  the 
lymphatic  glands  the  infectious  elements  of  carcinoma  find  most 
favorable  soil  for  exciting  epithelial  proliferation  of  the  tissue-cells. 

In  most  cases  no  causes  are  known  for  the  development  of  car- 
cinoma ;  but  in  many  cases  there  was  precedent  local  irritation,  that 
is,  the  neoplasia  developed  on  an  already  pathologically  changed 
base.  Recent  statistics  notice  local  irritations  at  the  point  of  de- 
velopment of  about  twenty  per  cent,  of  cases.  Not  to  go  further 
into  details,  I  may  mention  examples  of  development  of  carcinoma 
from  surfaces  that  have  suppurated  for  years,  such  as  fontanels, 
fistute,  etc.,  from  warts,  lupous  infiltrations,  etc.  Inheritance  seems 
to  be  a  cause  in  some  cases,  but  there  is  not  enough  evidence  on 
this  point.  Tendency  to  disease  of  the  same  system,  especially, 
seems  inherited,  without  the  same  organ  being  always  attacked  by 
carcinoma.     This  is  oftenest  seen  in  carcinoma  of  the  sexual  organs 


764  TUMORS. 

in  women,  e.  g.,  cancer  of  the  uterus  in  the  mother,  of  the  breast  in 
the  daughter,  and  the  reverse.  In  females  carcinoma  is  most  fre- 
quent in  the  glands,  in  men  in  the  skin. 

I  cannot  confirm  the  common  statements  about  cancerous  ca- 
chexia :  these  patients  finally  become  marasmic,  like  others  having 
severe  disturbance  of  important  organs,  indigestion  and  haemor- 
rhages ;  they  emaciate  rapidly  and  grow  yellow  or  brownish.  The 
general  condition  is  most  affected  in  cancer  of  the  tongue,  stomach, 
etc.  ;  but  where  it  does  not  bleed,  decompose,  or  interfere  with 
function,  the  patient  does  not  become  cachectic.  Some  patholo- 
gists even  consider  cancer  a  sign  of  superabundant  health  ;  without 
adopting  this  idea,  we  may  say  carcinoma  is  a  local  disease,  not  a 
symptom  of  a  general  affection,  as  a  gumma  is  of  syphilis.  For- 
merly, cancerous  diathesis  was  so  firmly  believed  in,  that  the  cure 
by  operation  was  discredited  ;  but  to-day  the  belief  has  changed. 
Experience  has  not  confirmed  a  popular  belief  that  cancer  is  infec- 
tious.] 

The  view  that  epithelial  cells  may  result  from  proliferation  of 
connective-tissue  cells  also  finds  supporters  among  the  new  school, 
who  either  do  not  recognize  the  typical  formation  of  the  tissue  from 
the  germ-layers,  or  else  do  not  acknowledge  its  significance  for  the 
pathological  neoplasiae.  Since  this  question  was  first  earnestly  dis- 
cussed it  has  come  up  repeatedly,  not  only  in  the  same  generations, 
but  to  the  same  person.  I  cannot  here  repeat  ^1  that  I  have  said 
about  the  origin  and  increase  of  true  epithelia  ;  I  will  merely  add 
that  the  carcinomatous  and  epithelial  forms  found  in  primary  cancer 
are  also  invariably  found  in  the  infecting  tumors  in  the  lymphatic 
glands.  This  seems  to  speak  strongly  in  favor  of  the  traveling  of 
cellular  elements,  for  it  is  scarcely  probable  that  the  fluid  from  a 
columnar  epithelial  cancer  should  influence  the  cells  in  the  lymphatic 
glands  to  produce  cylindrical  epithelium. 

From  the  peculiarities  described  (page  684),  even  in  the  most 
difticult  cases,  we  may  always  find  the  genetic  differences  between 
sarcoma  and  carcinoma.  The  first  commencements  of  sarcoma  and 
carcinoma  are  often  scarcely  distinguishable  (compare  Fig.  139  b 
with  162  and  163)  ;  both  cases  are  very  glandular  in  formation. 
But  things  change  after  a  time  ;  the  cell-cylinders  of  the  sarcoma 
have  either  started  from  vessels,  or  vessels  soon  grow  in  them  ; 
while  this  never  happens  in  carcinoma,  but  the  cylinders,  even  when 
quite  large,  remain  without  vessels,  or  else  a  cavity  forms  in  them 
as  in  the  development  of  glands  (compare  Fig.  139  b  with  169). 

I  dare  not  enter  further  into  the  general  histological  description 
of  these  tumors,  and  hope  you  will  be  able  to  recognize  them. 


CARCINOMATA. 


765 


When  speaking  of  sarcoma  I  said  something  about  the  difference 
of  its  course  from  that  of  carcinoma.  I  here  repeat  again  that  the 
latter  always  first  affects  the  adjacent  lymphatic  glands  ;  often  the 
infection  does  not  extend  beyond  them  ;  in  other  cases  there  may 
be  metastatic  tumors  in  internal  organs  or  the  bones.  The  small 
epithelial  germs  find  the  most  favorable  soil  for  their  development 
in  the  lymphatic  glands.  The  rapidity  of  the  course  varies  exceed- 
ingly ;  this  we  shall  consider  more  closely  when  treating  of  the  to- 
pography of  carcinoma. 

[In  some  well-observed  cases,  patients  who  had  been  cured  of 
cancer  of  the  skin  of  the  face,  without  having  disease  of  the  lym- 
phatic glands,  had  carcinoma  of  such  internal  organs  as  are  occa- 
sionally attacked  primarily  :  thus,  a  man  from  whom  cancer  of  the 
auricle  of  the  ear  was  removed,  had  a  cancer  of  the  stomach  running 
a  rapid  course  ;  in  a  patient  dying  after  a  rhinoplastic  operation  for 
epithelioma  of  the  nose,  carcinoma  of  the  intestines  was  found.  In 
such  cases,  from  absence  of  infection  of  the  lymj^hatic  glands,  we 
cannot  assume  metastasis,  particularly  to  organs  where  metastasis  is 
very  rare.  Hence  we  must  admit  the  possibility  of  a  double  disease 
affecting  two  distinct  places  in  a  patient  disposed  to  cancer.  This 
hypothesis  might  also  apply  to  cases  where  ten  years  or  more  after 
the  removal  of  a  cancer  another  develops  at  a  different  point.  Six- 
teen years  after  removal  of  cancer  of  the  tongue  there  was  cancer 
of  the  mucous  membrane  of  the  cheek,  without  recurrence  in  the 
tongue.] 

1.  Skin  (cutis)  and  mucous  membranes  with  pavement-epithelium, 
Common  epithelial  carcinoma  (specially  so  called  because  it  was  the 
first,  and,  until  lately,  the  only  form  in  which  the  main  body  of  the 
cancerous  tumor  was  known  to  consist  of  epithelium),  or  ca^icroid 
(cancer-like  tumors  ;  this  name  was  chosen  because  these  cancers  of  the 
skin  were  considered  less  malignant  than  those  forms  observed  in  the 
breast,  which  were  considered  as  the  type  of  true  cancer).  The  cutis 
is  covered  by  a  Ivtjer  of  epithelium,  from  which  in  the  foetus  there  are 
various  ingrowths  into  the  subjacent  tissue,  namely,  the  hair-folhcles, 
hair,  sebaceous,  and  sweat  glands.  Mucous  glands  are  formed  on  mu- 
cous membranes  in  the  same  way.  Many  assert  that  all  these  tissues 
may  have  epithelial  outgrowths.  I  shall  not  deny  this,  but  epithelial 
ingrowths  may  be  most  readily  proved  in  the  rete  Malpighii.  Next. 
to  this,  a  considerable  collection  of  epithelium  in  the  sebaceous  glands 
and  glands  of  the  oral  mucous  membrane,  and  their  enlargement,  are 
also  frequently  witnessed ;  less  frequently,  the  hair-follicles  and  sweat- 
glands  are  implicated.  During  this  ingrowing,  the  young  cells  of  tlie 
rete  at  first  preserve  their  size  and  form ;  even  their  relation  to  tje 
connective  tissue  of  the  cutis  remains  the  same,  for  those  cells  lying 


766 


TUMORS. 


Via.  152. 


GamBiencing  epithelial  cancer  of  the  vermilion  border  of  the  lip.— Growth  of  the  rcte  Malpiohii 
mto  the  tissue  of  the  lip.— Horny  epidermis.— The  blood-vessels  injected.  Ma.iiiflel  fiO 
diameters.  ° 


Pic.  153. 


ifSIIJP^^  °^^1l'^"'^  ',"^^^^T^  itu  r^  ?< ' «?'  %'\  l'???m' 


■*/« 


sgali 


w. 


*='>^ 

'.^ 


Pl«l  epithelial  cancer  of  the  cheeks.-Glandnlar  ingrowth  of  the  rete  Malpi-hii  into    hfl 
nective  tissue,  mfiltrated  with  email  cells.    Magnified  400  diaumers 


CARCINOMATA. 


767 


next  to  the  connective  tissue  preserve  a  cylindrical  form,  just  as  on 
the  normal  papillae  of  the  cutis. 

It  is  very  probable  that  the  epithelial,  gland-like  ingTowths  not  im- 
frcquently  grow  into  the  spaces  between  the  connective-tissue  bun- 


Ftq.  154. 


El.inonts  of  an  epithelial  carcinoma  of  the  lip.— (Fresh  preparation,  with  addition  of  very  dilute 

acetic  acid.)  a,  swingle  cells  with  endogenous  divis^ion  of  nuclei;  6,  a  cancroid  rod  with 
concentric  L'li)bules  and  outer  cylindrical  epithelium  ;  c,  an  epithelial  pearl  that  has  boeu 
crushed.    Magnified  400  diameters. 

dies  where  lymph  circulates,  for  there  the  tissue  offers  least  resistance, 
ICoster  thinks  he  has  proved  that  all  these  tubes  and  cylinders  lie 
Bolel}'  in  the  lymphatic  vessels.  Although  all  his  evidence  in  favor 
cf  this  view  is  not  tenable,  it  is  still  very  enticing,  for  we  might  then 
readily  understand  why  the  adjacent  Ij-mphatic  glands  were  occasion 
alJy  infected  early. 


r68 


TUMORS. 


Subsequently,  changes  take  place  in  these  epithelial  tubes  ;  groups 
of  cells  unite  and  form  globules,  which  gradually  grow  by  the  deposit 
of  new  cells  of  the  form  of  flat  epithelium,  and  thus  form  the  cabbage- 
like, compound  epidermis-globules  (globules  4pidermiques,  cancroid 
globules,  epithelial  pearls),  which  so  much  excited  the  astonishment 
of  the  first  person  that  examined  them. 

It  is  most  probable  that  these  globules  are  developed  from  a  num- 
ber of  conglomerated  cells,  increasing  by  division,  and  the  peripheral 
laj'ei's  of  cells  being  flattened  by  pressure  against  the  parts  around, 
which  are  not  very  distensible  ;  hence  the  larger  these  pearls  become 
the  more  they  project  from  the  cell-cylinders,  and  hence  they  often 
appear  at  the  terminal  points  of  the  glandular  acini.  Among  the 
cells  in  the  pearls,  as  in  the  epithelial  parts  of  these  tumors  else- 
where, we  often  meet  cells  with  many  nuclei ;  also  large  cell-bodies, 
which  have  enclosed  daughter  and  grandchild-cells.  In  some  of  these 
carcinomata  stachel  and  riff  cells  have  been  found  in  great  numbers, 
as  in  the  boundary  layers  between  the  mucous  and  horny  layers  of 
the  epidermis.  If  the  epithelial  masses  have  grown  deep  into  the 
tissue,  and  if  we  make  a  section  in  these  deeper  layers  of  a  hardened 
tumor  of  this  variety,  we  find  about  the  following  picture,  in  w'hich 
the  alveoli,  filled  with  epithelium,  may  readily  be  distinguished  from 
the  connective  tissue  which  has  become  faveolate  : 

Fig.  155. 


fc'rotu  an  epitbelial  cancer  of  the  hand,  the  blood-vessels  incompletely  injected.    Magnified  40C 

diameters. 


CARCINOMATA. 


(69 


The  vessels   in   this   connective-tissue  stroma  assume  a'uout  the 
shape  in  Fig.  156,  a,  while  Fig.  156,  5,  shows  a  proliferation  of  vessels 


Fig.  156. 


Vessels  from  a  carcinoma  of  the  peni?.  Mafrniflpd  60  diameters,  a,  from  the  developed  tu- 
mor tissue,  vascular  net-worl%  around  tlje  epidermis  pearls ;  b,  vascular  loops  from  the  sur- 
face of  the  indurated  but  not  yet  ulcerated  glaus  penis. 

in  the  enlarged  papillae  of  a  glans  penis,  as  it  occurred  just  at  the 
development  of  the  first  epithelial  proliferations. 

While  in  the  last-mentioned  case,  as  often  happens,  the  papillarv 
hypertrophy  appeared  at  the  very  commencement  of  the  developmen 
of  the  tumor  as  an  essentially  characteristic  part,  in  other  cases  it  li- 
of  an  entirely  secondary  natm'e,  i.  e.,  the  epithelial  rods  on  the  sur- 
face of  the  skin  or  mucous  membrane  soften,  fall  out,  and  leave  the 
vascular  connective-tissue  portion  in  the  form  of  a  pouclied  ulcer, 
from  which  different  papillary  tufts  protrude  or  subsequently  grow. 
Carcinoma  of  the  skin  may  begin  as  indurated  papilloma,  or  as  a  wart, 
but  just  as  often  it  begins  as  a  nodule  when  the  proliferation  is  at  first 
circumscribed,  grows  into  the  skin  ;  it  enlai-g6s  slowly,  without  grow- 
ing by  apposition  of  new,  small  carcinoma  nodules.  The  carcinoma- 
tous proliferation  may  also  enter  and  grow  through  the  cutis  from 
a  gradually-increasing  surffice,  without  causing  au}^  great  promi- 
nence. 

There  is  a  decided  difference  between  cancers  of  fhe  skin,  accord- 
ing as  the  epithelial  proliferation  enters  the  cutis  more  or  less  deeply ; 
some  cases  remain  quite  superficial,  scarcely  entering  tlie  subcuta- 
neous cellular  tissue,  and  growing  very  slowly  (fiat  epithelial  cancer, 
Thiersch) ;  others  grow  rapidly  and  enter  the  tissue  deeply,  destroy- 
ing it  (infiltrated  epithehai  cancer,  Thiersch).  The  above  dcscriptiop 
50 


770  TUMORS. 

of  cancer  of  the  skin  is  from  the  infiltrated  form  ;  in  flat  epithelial 
cancer  the  outgrowing  cell-cylinders  rarely  grow  deeper  than  the 
deep  layers  of  the  cutis,  and  consist  chiefly  of  the  small,  round  cells 
of  the  rete.  Along  with  these  proliferations  the  sebaceous  glands 
become  larger,  fill  up  with  developed  large-celled  epithelium,  and  the 
connective  tissue  is  richly  infiltrated  with  small-celled  elements.  In 
these  new  formations  the  development  of  epidermis  pearls  is  rela- 
tively rare.  As  viewed  on  the  patient  in  this  commencing  stage,  the 
whole  forms  a  hard,  slightly-elevated  infiltration  of  the  cutis,  covered 
with  desquamating  epidermis.  This  epithelial  proliferation  is  not, 
however,  very  solid ;  occasionally  there  are  disintegration,  softening, 
and  detachment  of  the  glandular  proliferations  and  sebaceous  glands. 
The  highly-vascular  connective  tissue  remains,  and  may  continue  to 
grow  as  granulations,  or  it  may  partially  cicatrize.  While  this  goes 
on  in  the  centre  of  the  new  formation,  the  latter  continues  to  grow,  it 
may  be  very  slowly,  in  the  periphery. 

At  their  very  commencement,  the  cut  surfaces  of  epithelial  cancer 
are  pale  red  and  hard ;  in  a  short  time  they  appear  white  and  granu- 
lar ;  occasionally  we  may  see  the  large  epithelial  pearls  and  rods  with 
the  naked  eye.  Ulceration  takes  place  from  without  inward,  even 
smore  frequently  than  by  medullary  softening  from  within  outward, 
and  usually  quickly  follows  their  development.  Mucous  softening  is 
rare  in  these  forms. 

In  regard  to  the  topography^  we  may  mention  the  following  regions 
of  the  body  as  the  most  frequent  seats  :  (a.)  Mead  and  neck  y  here 
these  tumors  develop  chiefly  on  the  eyelids,  conjunctiva,  skin  of  the 
nose  and  face,  the  lower  lip,  oral  mucous  membrane,  gums,  cheeks, 
tongue,  larynx,  oesophagus,  ear,  and  scalp.  The  first  appearance  va- 
ries greatly  :  the  worst  cases  begin  as  nodules  in  the  substance  of  the 
raucous  membrane  or  skin,  and  quickly  ulcerate  from  central  soften- 
mg  ;  other  cases  begin  on  the  surface ;  a  fissure,  crack,  indurated  ex- 
coriation, epidermoid  scab,  or  a  soft  vrart,  forms ;  this  at  first  apparently 
insignificant  afi'ection  may  remain  superficial  lor  a  long  time,  slowly 
extending  laterally,  less  so  in  depth,  and  having  indurated  borders. 
If  the  carcinoma  develop  from  a  wart-like  formation,  it  may  perma- 
nently preserve  the  papillary  character.  The  parts  once  diseased  are 
forever  destroj^ed  by  the  metamorphosis  into  cancerous  tissue;  in 
typical  epithelial  carcinomata  there  is  no  cicatricial  shrinking;  the 
ulcers  which  rapidly  develop  from  these  new  formations  vary,  like 
other  cancerous  ulcers ;  sometimes  smaller  or  larger  shreds  of  tissue 
from  the  depths  of  the  ulcer  become  gangrenous,  leaving  a  crater-like 
loss  of  substance ;  sometimes  the  new  formation  proliferates,  forming 
an   ulcer  with    fungous,   overgrowing   edges.      Not   unfrequently,  a 


CARCINOMATA.  77  ^ 

cheesy  pulp  may  be  squeezed  from  this  ulcerated  surface ;  it  comes 
out  in  a  worm-like  shape,  just  as  the  inspissated  sebaceous  matter 
does  from  the  glands  of  the  skin  (comedones  or  maggot)  ;  this  pulp 
is  a  mixture  of  softened  epithelial  masses  and  fat.  Sooner  or  later, 
there  is  a  gradually-increasing  swelling  of  the  neighboring  lymphatic 
glands  of  the  neck,  Avhich  is  not  unfrequently  painful ;  by  degrees 
the  glandular  tumors  unite  together,  or  with  the  primary  tumor ;  new 
points  break  out,  and  the  local  destruction  gradually  progresses ;  the 
new  formation  also  extends  in  depth,  destroying  the  bones  of  the  face 
or  skull,  and  taking  their  place.  Death  may  result  from  suffocation  or 
hunger,  due  to  pressure  of  the  tumor  on  the  air-passages  or  oesopha- 
gus, or  from  pressure  on  the  brain  after  perforation  of  the  skull ; 
more  frequently,  after  gradually-increasing  marasmus,  it  results  from 
complete  exhaustion,  with  the  signs  of  excessive  cachexia.  On  au- 
topsy, we  hardly  ever  find  metastatic  tumors  in  internal  organs. 
All  of  these  carcinomata  on  the  head,  face,  and  neck,  are  much  more 
frequent  in  men  than  in  women.  The  average  duration  of  life  of 
patients  with  cancer  of  the  tongue  and  oral  mucous  membrane  is  a 
year  to  a  3^ear  and  a  half.  Cancers  of  the  lips  are  radically  curable 
by  early  and  complete  extirpation. 

In  previous  works,  I  have  termed  the  above  form  of  flat  carcinoma 
of  the  skin,  "  cicatrizing,  atrophying,  epithelial  cancer,  or  scirrhoiu 
cutis,"  to  define  it  more  accurately  from  ordinary  epithelial  cancer. 
But  now  it  seems  to  me  better  to  make  no  special  subdi\asion  of  it, 
hence  I  at  once  state  that  this  is  the  mildest  form  of  cancer  of  the  skin, 
and,  with  few  exceptions,  attacks  old  persons ;  the  disease  occasion- 
ally begins  as  an  infiltration  of  the  papillary  layer,  with  small  nodules, 
always  superficial ;  usually  there  is  at  first  a  local  collection  of  yellow- 
ish epidermis,  a  small  scab,  after  whose  removal  the  skin  appears  at 
first  only  slightly  reddened,  scarcely  infiltrated ;  when  detached,  the 
crust  forms  again  ;  after  repeated  detachments,  we  find  under  it  a  small, 
rough,  fine  papillary,  dry,  ulcerated  surface,  which  occasionally  has, 
even  at  this  period,  hard,  slightly' -elevated  edges ;  the  small  ulcer,  on 
which  new,  dry  crusts  constantly  form,  extends  through  the  cutis,  but 
rarely  into  the  subcutaneous  tissue  ;  its  tendency  is  rather  to  spread 
laterally,  occasionally  it  even  heals  in  the  centre,  forming  a  cicatrix  and 
new  health}'-  epidermis,  while  a  moderate  induration  and  ulceration 
slowly  progress  in  the  periphery.  In  some  cases  there  is  no  ulcera- 
tion, only  infiltration  of  the  skin,  with  epidermis-scales  and  subse- 
quent cicatricial  shrinking. 

The  most  frequent  seat  of  flat  epithelial  cancer  is  the  face,  es- 
pecially the  cheeks,  brow,  nose,  and  eyelids ;  still  other  parts  of  the 
skhi,  which  are  subject  to  any  form  of  epithelial  carcinoma,  may  be 


772  TUMORS. 

attacked  by  this  form ;  it  is  most  frequent  between  the  fiftieth  and 
sixtieth  year,  and  I  find  it  as  often  in  women  as  in  men.  Often  the 
whole  cutaneous  surface,  and  especially  that  of  the  face  and  hands, 
appears  very  dry,  and  is  covered  by  numerous  dry,  fiat,  yellow  epider- 
mis-crusts, as  well  as  hy  numbers  of  small  infiltrations,  wliich  often 
disappear  again.  This  cancerous  infiltration  extends  very  slowly ; 
occasionally  it  is  six  or  eight  years  before  a  portion  of  skin  as  large  as 
a  dollar,  or  a  side  of  the  nose,  or  an  eyelid,  or  portion  of  the  ear,  is 
destroyed ;  it  rarely  proceeds  more  rapidly.  As  the  patients  are  gen- 
erally old,  they  occasionally  die  of  other  diseases,  and,  for  the  same 
reason,  there  is  often  no  recurrence  after  operation.  But,  even  in  cases 
not  operated  on  or  treated  in  any  way,  this  form  of  carcinoma  appears 
infectious  in  but  few  cases ;  the  infection  never  extends  beyond  in- 
filtration of  the  l^^mphatic  glands,  which  does  not  occur  till  late,  and 
then  goes  on  just  as  slowly  as  the  primary  infection.  Some  writers' 
have  wished  to  banish  this  form  of  cutaneous  cancer  from  the  lists  of 
carcinomata,  and  to  place  it  among  chronic  inflammations  as  ulcus 
rodens  [Hutchinson),  or  as  a  form  of  lupus  peculiar  to  old  j^ersons. 
The  various  combinations  of  this  neoplasia  with  distinctly-marked 
cancer  in  some  points  of  the  infiltrated  edges,  the  possibility  of  its 
changing  to  proliferating  cancer  of  the  skin,  and  some  other  anatomi- 
cal and  clinical  peculiarities,  render  it  certain,  in  my  opinion,  that  this 
form  of  infiltration  and  ulceration  belongs  among  the  cancers,  and  is 
the  mildest  and  most  feebly  infectious  among  them. 

{b.)  The  second  part  of  the  body  where  this  form  of  carcinoma  is 
frequent  is  about  the  genitals.  Tlie  portio  vaginalis  uteri,  vagina, 
xibia  minora,  and  the  clitoris,  the  penis,  especially  the  glans  and  pre- 
puce, are  the  parts  most  frequentl}'^  affected.  Of  all  these  parts,  the 
portio  vaginalis  uteri  is  especially  liable  to  the  disease,  and  here  car- 
cinoma ulcerates  rapidly,  and,  as  the  surface  of  the  tumor  becomes 
deeply  fissured  and  assumes  the  appearance  of  a  cauliflower,  this  is 
often  called  cauliflower  cancer,  but,  as  sarcomatous  papillomata  may 
produce  the  same  forms,  this  designation  is  uncertain.  On  all  of 
the  above  localities  the  ulcerated  tumor  may  have  a  destructive  ul- 
cerating or  a  fungous  character,  it  may  also  be  either  infiltrated 
or  superficial.  The  separation  of  uterine  cancer  is  accompanied  by  very 
badly-smelling  sanies,  and  often  with  repeated  parenchymatous 
haemorrhages.  As  regards  the  subsequent  course  of  the  disease,  the 
retroperitoneal  lymphatic  glands  are  affected  sooner  or  later ;  death 
usually  results  from  marasmus ;  in  these  cases,  also,  we  very  rarely 
find  metastasis  in  the  internal  organs,  except  in  the  neighboring 
glands  which  are  directly  infected. 

(c.)  Of  other  parts  of  the  body  that  require  the  attention  of  the 


CARCINOMATA. 


773 


surgeon,  we  have  to  mention  the  hand,  and  especially  the  back  of  the 
hand.  Not  long  since,  I  saw  an  epithelial  carcinoma  on  the  right 
forearm,  which  had  developed  from  a  fontanel,  kept  up  for  ten  years 
with  peas.  I  also  saw  an  ulcer  of  the  foot,  which,  after  lasting  for 
years,  without  any  known  cause  became  cancerous. 

{d.)  We  also  mention  here  the  carcinomata  growing  from  the 
vesical  mucous  membrane,  which  also  has  a  pavement  epithehum. 
Inaccessible  as  it  is  for  surgical  treatment,  the  surgeon  must  still  be 
well  acquainted  with  it,  to  enable  him  to  make  a  diflferential  diagnosis. 
It  has  already  been  frequently  mentioned  that  papillary  proliferations 
occur  in  carcinoma ;  this  is  particular!}'  often  the  case  in  cancers  on 
the  inner  surface  of  the  bladder,  which  frequently  grow  in  the  shape 
of  branched  villi,  and  have  consequently  received  the  special  name 
of  "  villous  cancer." 

Cancers  starting  from  the  cutaneous  epithelium  and  glands  have 
the  same  relation  to  villous  cancer  that  adenoma  has  to  papilloma. 
When  papilloma  assumes  a  peculiarly  luxuriant  growth,  and  at  the 
same  time  epithelial  masses  grow  into  the  part  of  skin  affected,  soft- 
ening the  connective  tissue  or  muscle,  in  short,  when  the  tumor  as- 
sumes a  distinctly  destructive  character,  it  may  be  regarded  as  car- 
cinomatous papilloma   or  \allou8   cancer.     The  boundaries  between 


Fig.  157. 


PaylUary 


formation  of  a  villous  cancer  of  the  bladder,  after  LnmM     a    without.  6,  with  epi 
toeUum"  °:  isoYalTepitUelial  cells  of  the  villi.    Ma;,anfled  3-.0  di.ia.erers. 


774  TUMORS. 

simple  papilloma  and  villous  cancer  may  be  just  as  difficult  to  define 
as  those  between  adenoma  and  carcinoma. 

As  abqve  stated,  a  tumor  like  a  mushroom  forms  on  the  inner  sur- 
face of  the  bladder,  growing  into  its  cavity,  and  floating  in  the  urine, 
its  base  being  attached  to  the  wall  of  the  bladder,  like  a  carcinoma, 
and  its  long,  branched  villi  being  covered  with  very  large  epithelial 
cells,  wliile  the  ground-work  of  the  papillae  is  composed  of  connective 
tissue,  whose  meshes  contain  epithelial  cell-cylinders,  such  as  occur 
in  carcinoma  (Fig.  157). 


Now,  a  few  words  about  the  course  of  the  above  carcinomata  as  a 
class.  They  usually  appear  in  elderly  persons,  say  from  the  fortieth 
to  sixtieth  year,  rarely  later,  but,  unfortunately,  it  is  not  so  rare  for 
them  to  come  earlier ;  I  have  seen  cancer  of  the  tongue  in  a  boy  of 
eighteen,  and  cancer  of  the  uterus  in  a  woman  of  twenty  years.  On 
the  whole,  country  people  are  more  subject  to  cancer  of  the  lip  than 
city  people  are.  The  earlier  these  carcinomata  appear,  the  more  pro- 
liferant  the  local  tumor,  the  earlier  the  lymphatic  glands  are  implicated, 
and  the  more  rapid  the  whole  course.  It  has  often  been  observed 
that,  after  entire  removal  of  the  tumor,  there  is  no  recurrence.  In 
some  cases  the  disease  runs  its  course  very  quickly,  in  a  year ;  in  oth- 
ers it  lasts  three,  five,  ten  years,  or  longer  (flat  cancer  of  the  skin)  ; 
sometimes,  also,  the  recurrence  is  only  in  the  lymphatic  glands,  as 
when  a  cancer  of  the  lip  has  been  comp.etely  extirpated,  but  at  the 
time  of  operation  cancer-germs  were  already  present  in  the  cervical 
lymphatic  glands.  The  new  formation  in  the  gland  at  first  appears 
pale  red,  is  a  rather  hard,  diffuse  infiltration,  or  a  white  kernel,  but 
with  time  it  becomes  softer,  and,  to  some  extent,  pulpy  and  purulent. 
Tlie  cervical  lymphatic  glands  infiltrated  with  cancer  have  a  great 
tendency  to  ulcerate  ;  their  microscopical  structure  is  the  same  as  that 
of  primary  cancer.  I  think  there  is  no  doubt  that  secondary  cancer 
in  the  lymphatic  glands  is  always  due  to  transplantation  of  cancer- 
germs  from  the  original  focus  (see  page  6T1).  The  above  forms  of 
cancer  scarcely  ever  go  beyond  the  lymphatic  glands ;  infection  of  in- 
ternal organs  (liver,  lungs,  spleen,  kidne3's)  is  very  rare.  The  con- 
stancy with  which  carcinoma  occurs  at  certain  points,  especially  where 
mucous  membrane  passes  into  skin  (vagina,  penis,  lips),  has  justly 
always  excited  much  attention.  It  was  natural  to  seek  the  causes  of 
the  disease  in  the  structure  of  these  parts,  and  in  the  irritations  to 
which  these  openings  were  subjected ;  the  dislike  that  most  modern 
pathologists  have  to  specific,  unknown  irritations  has  induced  them  to 
seek  different  reasons  for  explaining  the  obscurity  about  the  specific 


CARCINOMATA.  775 

jauses  of  tumors  of  these  parts.  In  regard  to  the  lips  in  old  persons, 
Thiersch  attaches  great  importance  to  the  fact  that  there,  as  in  the 
cutis  elsewhere,  considerable  changes  take  place  with  advancing  age : 
there  is  decided  atrophy  of  the  connective  and  muscular  tissues,  so 
that  the  epidermis-formations,  hair-folHcles,  sebaceous  and  perspira- 
tory glands,  as  well  as  those  of  the  lip,  attain  the  preponderance,  and 
receive  most  of  the  nourishment;  hence  all  irritations  affecting  the 
lips  (bad  shaving,  smoking  tobacco,  wind,  bad  weather,  etc.)  chiefly 
attack  the  glandular  parts  of  the  lip,  and  induce  hyperplasia.  In 
England,  epithelial  cancer  often  attacks  the  scrotum  of  chimney- 
sweeps (chimney-sweeper's  cancer),  from  the  irritation  of  the  soot,  it 
is  supposed.  These  things  may  certainly  have  some  effect,  but  it  re- 
mains unexplained  wliy  they  should  be  followed  by  cancers  or  infec- 
tious tumors,  and  not  by  chronic  inflammations,  catarrhs,  etc.  I  shall 
not  here  follow  this  discussion  further,  but  merely  refer  you  to  what 
was  said  about  the  etiology  in  the  introduction  to  the  section  on 
tumors. 

2.  Mammary  glands.  I  place  cancer  of  the  mamma  here,  as  this 
gland  is  also  a  derivative  of  tlie  epidermis,  a  cutaneous  fat-gland  on  a 
large  scale.  Tlie  mammary  cancers,  however,  differ  greatly  from  those 
already  described,  and,  although  true  epidermis-cancers  occur  in  the 
breast,  starting  particularly  from  the  areola,  they  are  verj-  rare. 

Mammary  cancer,  which  is  unfortunately  very  frequent,  seems  to 
me  almost  always  to  begin  with  a  coincident  enlargement  of  the  small, 
round,  epithelial  cells  in  the  acini,  and  with  small-celled  infiltration 
of  the  connective  tissue  around  them.  With  our  present  methods  of 
examination  it  is  impossible  to  tell  whether  the  first  changes  occur 
in  the  gland-cells,  or  in  the  connective  tissue;  for  the  grouping  of 
small,  round  cells  about  the  acini  soon  becomes  so  excessive,  tliat  it 
constantly  becomes  more  difficult  to  make  out  the  further  fate  of  the 
glandular  acini.  From  my  tolerably  numerous  observations  on  this 
subject,  made  by  aid  of  the  most  improved  methods,  I  think  I  may  de- 
scribe the  following  as  the  subsequent  course : 

The  collection  of  cells  in  the  acini  leads  first  to  their  enlargement, 
which  is  occasionally  accompanied  by  a  trace  of  secretion  (as  is  showTJ 
by  the  escape  of  serum  from  the  nipple).  As  the  collection  of  cells 
c<mtinues,  there  is  more  enlargement  of  the  acini,  and  in  such  different 
ways,  that  we  may  distinguish  an  acinous  (often  large-celled)  and  a 
iubular  (chiefly  small-celled)  form  of  mammary  cancer.  The  former 
'cads  to  the  development  of  large,  lobulated,  glandular  nodules;  hence 
I  call  this  the  "acinous  form,"  since  in  it  the  rough  outlines  of  the 
acini  are  preserved.  The  following  picture  is  a  slightly-magnified  oni; 
of  the  borders  of  such  a  tumor : 


776 


TUMORS. 

fiG.  158. 


^Innim:iry  cnnccr,  acinous  form.    Magnified  50  diameters. 


The  groups  of  epithelial  cells,  which  are  enlarged  and  grown  to 
thick  glandular  clubs,  are  enclosed  by  infiltrated  connective  tissue, 
and  traversed  by  a  fine  net-work  of  connective  tissue  (stroma),  which 
I  regard  as  the  remains  of  the  former  partitions  between  the  acini, 
but  which  others  consider  as  mostly  new  formation. 


Hoft  raammai-y  cancer;  alveolar  tisstie  of  the  carcinoma;  alcoholic  preparation     Magnifled 

100  diameters. 


CARCINOMATA. 


777 


If  we  make  a  section  through  a  hardened  preparation  of  an  aci- 
nous, soft,  mammary  cancer,  when  magnified  more  strongly,  the  tissue 
appears  as  above.  I  consider  the  cells  in  the  large  connective-tissue 
meshes  as  of  epithelial  origin  (Fig.  159). 

This  variety  of  mammary  cancer  is  mostly  soft,  granular  on  section, 
grayish  white  (medullary).  If  we  scrape  the  cut  surface  of  such  a 
cancerous  tumor,  we  readily  evacuate  a  thick,  whitish  pulp;  if  we  ex- 
amine this  while  fresh,  we  find  nodular  cells,  very  pale,  composed  of 
large,  many-formed  cells  with  large  nuclei ;  many  of  these  cells  contain 
several  nuclei ;  they  may  perhaps  be  segregating. 

The  connective-tissue  frame-work  in  which  these  elements  were 
embedded,  Avhen  empty,  looks  about  as  follows,  if  strongly  mag- 
nified : 

The  second  form,  which  is  more  frequent  (is  harder,  and  on  section 
pale  red),  may  be  termed  the  "  tubular  "  form,  as  the  acini  do  not 
maintain  their  form,  but  grow  into  the  connective  tissue  as  very  thin 
cell-cylinders,  while  it  becomes  infiltrated  with  cells.  As  in  this  form 
Ci  cancer  the  cells  from  the  epithelium  do  not  usually  grow  so  large 
as  in  the  preceding  form,  and  as  the  cells  collected  in  the  connectivn 

Fia.  160 


Frutn  a  mammary  cancer.    Magnified  300  diameters,    a.  cells  with  several  nnrlei  (fresh  ^rcDS- 
raUon,Tilh  "omewatei?added);  b,  glandular  ceU-cylinders  (fresh  preparatiou;. 

tissue  occasionally  lie  together  in  groups,  it  is  evident  that  it  must  be 
very  difficult  to  decide  which  of  these  cancers  come  from  the  ceU- 
inasses  of  glandular  epithelium,  and  which  are  pure  derivatives  of 
connective  tissue,  former  wandering  cells. 


778 


Comiective-tifsue  frarae--work  of  a  cancer  of  the  breast ;  the  thick  etrise  are  plentifully  infil- 
trated with  young  cells.    Brushed-out  alcohol  preparation.    Magnifled  100  diameters. 

Hence  all  observers  are  not  yet  convinced  that  these  frequent 
forms  of  mammary  carcinomata  are  true  cancer,  as  some  of  tlioui 

Fig.  162. 


Cancer  of  the  breast ;  tubular  form.    Magnified  150  diameters. 


CARCINOMATA.  779 

regard  all  tlie  cells  occurring'  here  as  derived  from  connective  tissue. 
The  final  decision  in  this  matter  can  only  be  made  by  the  history  of 
development;  as  long  as  we  have  no  means  of  always  distinguishing 
the  young  derivatives  of  epithelial  cells  from  wandering  white  blood- 
cells,  and  the  derivatives  of  connective  tissue,  we  shall  scarcely  be 
able  to  say  from  every  preparation  whether  this  form  of  cancer  of  the 
mamma  is  more  of  an  epithelial  or  connective-tissue  nature. 

Although  all  forms  of  cancer  of  the  breast  have  a  tendency  to 
ulcerate,  this  is  more  the  case  in  the  softer  than  in  the  harder  forms. 
The  hardness  of  cancer  of  the  mamma  does  not  always  depend  on  its 
richness  in  cells,  but  even  acinous  cancers  that  are  rich  in  cells  may 
be  hard,  if  the  cells  are  enclosed  in  tense  connective-tissue  capsules, 
as  the  normal  acini  are.  The  softening  is  central  in  nodules  lying 
near  the  skin,  or  in  the  harder  forms  it  is  more  frequently  from  with- 
out inward  at  points  where  the  tumor  presses  against  the  skin  and 
has  become  united  to  it.  Mucous  softening  occurs  rarely,  mucous 
metamorphosis  of  the  gland-cells  is  probably  never  seen.  To  the 
naked  eye  the  softened  spots  appear  whitish-yellow,  granular  (cas- 
eous, fatty  softening)  or  grayish  or  dark  red  from  vascularity,  espe- 
cially if  there  have  been  extravasations.  By  softening  and  encap- 
sulation of  the  softened  spot,  which  may  be  deeply  seated,  cysts  may 
be  formed  in  these  carcinomata ;  retention  and  secretion  cysts  may 
also  be  developed  in  the  mamma  along  with  or  in  the  cancerous 
tumor. 

Fig.  163. 


Onncev  of  the  mr.mma,  from  a  cicatiicuilly-atrophied  part.    M:i-iiiUeJ  -m  diaraeiors. 

Atrophy  is  a  very  frequent  process  in  cancer  of  the  mamma ;  the 
ripple  or  other  parts  are  thus  retracted  like  the  navel.  On  micro- 
scopic examination  of  these  atrophied  parts  we  see  connective-tissue 
striie  mth  atrophied  connective-tissue  corpuscles,  and  the  section  of 
fine,  branched  canals  (atrophied  alveoli)  which  are  filled  with  cell 


780 


TUMORS. 


detritus  or  fat.  This  atrophy  of  the  new  formation  is  in  some  cancers 
of  the  mamma  such  an  important  factor,  that  it  has  given  rise  to  a 
special  form  of  cancer,  "  atrophying,  cicatrizing  cancer."  It  cannot  be 
denied  that  in  its  pure  form  this  variety  of  cancer  has  certain  pecu- 
liarities which  distinguisli  it  from  the  ordinary,  most  frequent  forms 
of  cancer  of  the  mamma ;  hence  we  prefer  to  describe  it  separately 
hereafter. 

The  development  of  cancer  of  the  mamma  is  accompanied  by  con- 
siderable distention  of  vessels  and  new  formation.  In  the  youngest 
parts  of  the  new  formation  there  are  numerous  fine  vessels  and  netr 
works  of  vessels ;  in  the  older,  especially  in  the  softening  parts,  the 
vessels  grow  wider,  then  are  thrombosed  and  destroyed,  so  that,  about 
points  of  softening  in  tumors,  similar  net-works  of  dilated  vessels 
form  as  are  developed  on  the  formation  of  abscesses. 

The  following  are  the  clinical  symptoms  of  the  development  and 
course  of  ordinary  cancer  of  the  mamma.  The  disease  usually  begins 
between   the  thirtieth  and  sixtieth  year,  rarely  earlier  or  later;  the 


Fio.  104. 


Vascular  net-work  from  a  veiy  young  cancerous  nodule  of  the  mamma.  Magnified  50  diameters. 

women  attacked  are  usually  otherwise  perfectly  healthy ;  married  and 
unmarried  women,  fruitful  and  barren  wives,  of  all  conditions,  are  at- 
tacked. Not  unfrequently  the  parents  or  grand-parents  have  died  of 
carcinoma.  Most  frequently  in  one  breast,  especially  in  the  outer  and 
lower  part,  there  forms  a  tumor,  at  first  small  and  painless,  that  some- 
times remains  unnoticed  for  months;  it  is  hard,  firmly  seated  in  the 


CARCINOMATA.  ^gj 

Pkj.  165. 


Vascular  net-work  around  points  of  softening  in  a  cancer  of  tiie  breast.  Ma-niSed  50  diameters. 


gland,  but  at  first  movable  under  tbe  skin  and  over  the  pectoral  mus- 
cles ;  at  first  its  gi-owtli  is  moderately  rapid ;  possibly  a  year  passes 
before  the  tumor  reaches  the  size  of  a  small  apple ;  its  volume  is  not 
always  the  same,  occasionally  it  is  larger  and  more  sensitive,  especially 
before  and  during  the  menses ;  but  occasionally  the  tumor  collapses 
somewhat,  and  is  perfectly  indolent.  These  sj'mptoms  are  partly 
dependent  on  congestion  of  the  mammary  gland,  partly  on  atrophy 
and  cicatrization  going  on  in  the  tumor  itself.  With  time,  in  the 
course  of  some  months,  the  tumor  grows  larger ;  the  skin  over  it  be- 
comes immovable,  and  below  it  adheres  to  the  pectoral  muscle.  The 
patients  frequently  do  not  notice  the  commencement  of  the  swelhng 
of  the  axillaiy  glands,  and,  if  the  surgeon's  attention  be  not  occasion- 
ally directed  to  this  region,  the  enlargement  of  these  glands,  which 
appears  as  a  hard  swelling  of  these  parts,  is  not  discovered  till  late  ; 
sometimes  also  these  glands  lie  so  deep  and  so  high  under  the  pectoral 
muscle  that  they  are  not  felt  till  they  have  grown  quite  large.  The 
lymphatic  glands  of  the  neck  are  less  frequently  affected  in  cancer  of 
the  breast ;  when  they  are,  the  prognosis  is  more  unfavorable.  If  the 
progress  of  the  tumor  goes  on  undisturbed,  the  course,  when  moder- 
ately rapid,  is  as  follows :  Tlie  tumor  of  the  mammary  gland  and 
those  of  the  axillary  glands  gradually  unite,  so  as  to  form  a  nodular, 
wavy,  immovable  swelling,  which  at  some  points  adheres  to  the  skin ; 
the  pressure  of  the  tumor  on  the  nerves  and  vessels  in  the  axilla 
causes  neuralgic  pains  and  oedema  in  the  arm  ;  the  patients,  who  pre- 
viously had  felt  perfectly  well,  are  compelled  to  keep  in  bod  by  the 
pain  and  swelling  of  the  arm,  which  come  on  more  especially  at  night, 
and  have  a  piercing,  boring  character,  while  previously  they  may  have 


782  TUMORS. 

been  able  to  attend  to  tlieir  household  duties.  In  this  stage  (say  twc 
years  after  the  commencement  of  the  first  tumor)  another  symptom 
has  usually  .appeared,  or  does  so  shortly,  namely,  ulceration.  This 
generally  begins  with  the  following  symptoms  :  Part  of  the  tumor  be- 
comes prominent,  the  skin  grows  thinner  and  redder,  is  traversed  by 
visible  vessels ;  finally  a  fissure  or  vesicle  forms  on  the  elevated,  red, 
fluctuating  tumor ;  now  part  of  the  cancerous  tissue  which  is  exposed 
to  the  air  becomes  gangrenous,  breaks  into  shreds,  and  a  crater-like, 
excavated  ulcer  is  left,  which  long  maintains  this  shape,  if  the  stir- 
roundings  and  base  of  the  ulcer  be  still  hard ;  but,  if  the  parts  about 
the  ulcer  be  already  soft,  the  substance  of  the  tumor  begins  to  prolif- 
erate at  the  edges  and  from  the  depths,  and  to  cover  the  parts  around 
like  a  fungus.  An  ulcer,  sometimes  torpid,  sometimes  fungous,  is 
thus  developed  ;  its  secretion  is  always  sero-sanious ;  badly-smelling, 
gangrenous  shreds  are  often  thrown  oflF.  But,  what  is  still  worse, 
parenchymatous  or  even  arterial  haemorrhages  occasionally  occur  from 
the  surface  of  the  ulcer,  and  exhaust  the  patient.  "SYe  have  followed 
the  condition  of  the  patient  till  he  has  become  partly  or  entirely  bed- 
ridden ;  we  now  soon  come  to  the  catastrophe :  the  patient  becomes 
pale  and  greatly  emaciated  ;  the  appetite  is  lost,  the  strength  grows 
less,  the  nights  are  often  sleepless  from  the  pain ;  opiates  must  be 
rt^sorted  to,  to  give  the  patients  sleep  and  temporary  relief.  We  now 
have  the  well-marked  picture  of  cancerous  dyscrasia  or  cachexia.  It 
may  go  on  in  this  way  for  months ;  the  smell  from  the  cancerous  ulcer 
infests  the  chamber,  the  patients  become  weaker,  the  skin  grows 
grayish-yellow  and  clayey.  Pains  on  breathing  and  in  the  region  of 
tlie  liver,  as  well  as  in  the  bones  of  the  limbs,  come  on.  The  patient 
becomes  marasmic,  and  dies  in  agony  after  protracted,  painful  suffer- 
ing, unless  tlie  end  is  hastened  by  pleurisy  or  peritonitis.  On  au- 
topsy, in  most  cases  we  find  carcinomatous  tumors  of  the  pleura, 
liver,  and  occasionally  of  the  bones,  it  may  be  of  the  femur  or  of  the 
vertebrae,  or  else  of  the  ribs  on  the  side  M'here  the  tumor  of  the 
breast  Avas.     The  whole  disease  has  lasted  two  years  and  a  half. 

For  many  cases  of  cancer  of  the  breast  the  above  description  will 
be  very  accurate,  but  there  are  some  modifications  of  this  course. 
First,  the  rapidity  of  the  local  course  varies ;  the  tumor  may  remain 
confined  to  the  breast,  without  any  affection  of  the  lymphatic  glands 
— a  very  rare  case.  The  disease  of  the  glands  appears  almost  simul- 
taneously with  the  tumor  of  the  breast ;  this  always  leads  us  to  ex- 
pect a  very  rapid  course  of  the  disease,  while  conversely  a  very  late 
and  moderate  local  spread  to  the  lymphatic  glands  indicates  a  mild, 
slow  course  of  the  whole  disease.  Carcinomata  may  come  in  the  two 
breasts  siraultaneousl}',  or  in  one  soon  after  the  other ;  this  makes  the 


CARCINOMATA.  733 

prognosis  much  worse.  In  some  cases  there  is  no  isolated  tumor  of 
the  breast,  but  the  whole  gland,  with  the  skin,  becomes  diseased  at  the 
same  time.  Lastly,  an  adenoma  or  an  adeno-sarcoma  may  have  ex- 
isted eight  or  ten  years,  and  then  rapidly  assume  tlie  character  of  a 
cancer,  i.  e.,  become  immovable,  painful,  and  accompanied  by  harden- 
ing of  the  lymphatic  glands.  Cases  also  occur  where  the  tumor  of 
the  mamma  diminishes  so  much  that  it  is  supposed  it  has  entirely  dis- 
appeared ;  unfortunately,  this  does  not  prevent  the  general  outbreak 
of  the  disease,  although  it  appears  to  retard  it,  or  only  to  occur  in 
mild  cases,  such  as  run  on  from  four  to  six  years.  Some  patients  die 
early  of  anemia  from  the  ulceration  and  haemorrhage,  without  any 
metastatic  tumors  having  formed.  The  period  for  the  occurrence  of 
metastatic  cancerous  tumors  in  the  internal  organs  also  varies ;  gener- 
ally,  when  the  local  growth  of  the  tumor  is  slow,  metastatic  tumors 
appear  late ;  still,  there  are  exceptions  to  this  rule.  In  cancer  of  the 
breast  the  localization  of  the  secondary  tumors  is  very  regular,  as 
already  stated  '  the  pleura,  liver,  and  bones,  are  the  most  frequent  seats 
of  metastatic  tumors. 

The  varying  course  of  cancer  of  the  breast  renders  it  very  diffi- 
cult, indeed  almost  impossible,  to  compare  the  result  of  early  or  late 
operations  with  those  cases  that  run  their  course  without  operation  ; 
even  the  age  of  the  patient  causes  great  diiferences :  in  old  persons, 
the  disease  almost  always  runs  a  slower  course  than  in  young  ones ; 
luimerous  entirely  imknown  influences  come  in  play.  The  most  ex- 
perienced surgeons  have  given  very  different  opinions  about  operating, 
some  declaring  that  the  course  of  the  disease  is  hastened  by  operation, 
others  that  it  is  retarded.  The  statistical  tables  that  have  been  pub- 
lished aid  little  in  solving  this  question,  because  cases  of  all  sorts  are 
thrown  together  in  them ;  to  obtain  a  correct  result  from  them,  the 
cases  must  first  be  sejDarated  on  certain  principles.  But  what  good 
would  this  do  ?  It  would  always  be  a  question,  in  each  case,  whether 
we  should  aid  the  patient  by  an  operation  or  not.  The  tumors  will 
almost  always  return  in  the  cicatrix,  in  its  vicinity  or  in  the  neighbor- 
ing lymphatic  glands,  because  they  are  usually  operated  on  too  late  ; 
the  patients  will  then  die  of  metastatic  tumors,  if  they  are  not  carried 
off  sooner  by  suppuration,  hsemorrhage,  or  acute  disease.  How  much 
does  the  patient  suffer  from  the  tumor  ?  What  danger  does  it  induce 
locally  ?  These  are  the  first  urgent  questions.  But  I  am  anticipating 
by  considering  here  the  treatment,  which  we  propose  studying  more 
attentively  at  the  end  of  this  section  on  cancerous  diseases.  Exami- 
nation of  the  enlarged  lymphatic  glands,  which  partly  adhere  together, 
shows  that  the  smaller  are  more  succulent  and  vascular  than  normal ; 


784  TUMORS. 

the  larger  contain  hard  "vvhite  or  graj-ish-white  nodules,  and  are  occa- 
sionally softened,  caseous,  and  have  a  granular  cut  surface.  On  the 
whole,  the  lymphatic  glands  show  the  same  characters  as  primar}^  can- 
cers ;  tliis  also  extends  to  the  microscopic  texture.  Although  it  could 
probably  only  be  proved  in  pigmented  carcinoma  that  the  first  swell- 
ing of  the  lymphatic  glands  depends  on  transformation  of  tumor-cells 
into  the  lymphatic  glands,  still  I  consider  the  same  thing  true  of  alj 
carcinomata;  in  some  cases  the  epithelial  nature  of  the  new  forma- 
tion in  the  lymphatic  glands  is  just  as  striking  as  in  the  primary  tumor 
of  the  breast,  in  others  such  a  distinction  is  impossible. 

Carcinomatous  nodules  of  the  pleura,  which  develop  after  car- 
cinoma of  the  breast  from  direct  conduction  of  the  seeds,  are  usually 
hard,  pure  white,  and  small-celled ;  the  same  is  true  of  the  external 
appearances  of  secondary  cancer  of  the  lungs  and  liver  ;  but  the  latter 
are  not  unfrequently  large-celled  and  acinous.  Although  I  regard  it 
as  probable  that  these  carcinomata  are  also  due  to  direct  emigration 
of  carcinoma-cells  or  to  transportation  of  the  latter  by  the  lymphatic 
or  blood  vessels,  this  cannot  be  proved. 


Some  cases  deviate  from  the  above  course,  as  is  shown  by  early 
and  continued  shrinking  of  the  new  formation.  This  form  is  called 
scirrhus  mammce,  atrophying,  cicatrizing,  shrinking  carcinoma,  con- 
nective-tissue cancer.  The  picture  of  the  disease  and  the  anatomical 
changes  will  appear  from  what  follows. 

In  the  mammary  gland,  rarely  before  the  fiftieth  year,  there  forms 
a  hard  spot — we  cannot  say  a  swelling — but  the  hardening  is  rather 
accompanied  by  a  partial  or  even  a  total  decrease  in  size  of  the  gland ; 
this  hardening  usually  forms  without,  rarely  Avith  severe  pain  ;  it  comes 
on  very  slowly.  If  we  now  suppose  the  hardened  glands  removed 
and  examine  the  diseased  portion,  we  find  the  tissue  so  hard  that 
we  can  scarcely  cut  it ;  to  the  naked  eye,  the  cut  surface  shows  a  hard, 
fibrous  cicatrix,  with  connective-tissue  stria?  gradually  extending  into 
the  comparatively  healthy  parts  around.  In  typical  cases,  except  this 
cicatrix,  we  shall  scarcely  discover  any  thing  pathological  with  the 
naked  eye ;  but,  at  the  periphery  of  some  of  these  tumors  we  see  a 
pale-reddish  part  with  a  fatty  lustre,  more  marked  in  spots,  lying  be- 
tween the  cicatrix  and  the  healthy  tissue,  and  passing  into  both.  If 
we  examine  fine  sections  of  the  cicatricial  tissue  after  previously 
hardening  it  still  more  in  alcohol,  we  find  little  besides  connective 
tissue  and  elastic  filaments ;  but  the  connective-tissue  striae  have  not 
the  same  peculiar  regular  course  that  they  have  in  fibroma  ;  they  are 
irregularly  intertwined,  and,  as  above  stated,  they  are  accompanied 


C^ROINOMATA. 


785 


bv  many  elastic  filaments,  which  rarely  happens  in  fibroma.  But 
examination  of  the  bordering  tissue  gives  the  following :  There  is 
cell-infiltration,  to  a  very  slight  extent,  it  is  true ;  there  is  development 
of  small  groups  of  pale  bodies,  Hke  lymph-cells,  with  single  nuclei,  as 
in  the  commencement  of  any  new  formation.  Part  of  these  cells  are 
arranged  in  long  groups  (tubular),  somewhat  larger  than  the  rest; 
these  are  doubtless  derivatives  from  the  epithelial  remains  of  the 
shrunken  glandular  acini.  All  the  cells  of  the  neoplasm  appear  to  be 
very  short-lived,  for  they  are  scarcely  formed  before  they  commence 
'o  decay,  without  going  on  to  further  development ;  then  the  con- 
nective tissue,  which  has  been  somewhat  distended,  shrinks  together, 
and,  as  a  result  of  this  process,  we  have  the  cicatrix;  but  peripherally 
this  slight  cell-infiltration  constantly  extends ;  hence  complete,  spon- 
tiineoufj  disappearance  of  the  new  formation  very  rarely,  if  ever,  occurs. 
If  the  borders  of  this  tumor  be  inspected  under  a  low  power  of  the 
'uicroscope,  we  see  how  the  small-celled  infiltration  advances  between 
'lie  meshes  cf  the  connective  tissue,  and  closely  foUows  them. 

Fig.  166. 


Connective-tissue  infiltration  advancing  into  tlie  cutis  from  the  borders  of  a  caiicerous  nortnJo 
of  the  mamma;  the  dark  shadings  correspond  to  the  advanciug  small-celled  inUltrai.on. 
Magnified  50  diameters. 

The  extension  of  this  infiltration  into  the  fatty  tissue  occurs  just 
as  m  inflammation  ;  most  of  the  young  cells  are  found  in  the  vicinity 
of  the  vessels,  so  that  we  can  scarcely  avoid  thinking  that  in  tliese 
cases  also  white  blood-cells  escaping  from  the  vessels  cause  the  cellu- 
lar infiltration. 

As  in  these  cases  the  infiltration  of  the  connective  tissue  with 
61 


786 


TUMORS, 


lymphoid  cells  is  very  decidedly  the  predominant  morbid  process, 
while  the  epithelial  proliferation  is  very  secondary,  I  formerly  tried  to 
give  this  form  of  cancer  of  the  breast  the  name  of  "  connective-tissue 
cancer."  But,  as  this  has  led  to  misinterpretation  in  regard  to  the 
modern  anatomical  understanding  of  carcinoma,  I  shall  not  try  to 
preserve  this  term. 

Fig,  167. 


Cellular  infiltration  of  the  fatty  lisstie  in  tlie  periphery  of  a  hard  cancer  of  the  hreast ;  the  blood- 
vessels iujuctcd.    Ma^uitied  200  diameters. 


The  peculiar  anatomical  and  clinical  course  has  caused  some  sur- 
geons to  strike  this  new  formation  from  the  list  of  tumors,  and  par- 
ticularly from  that  of  cancers.  If  we  examine  more  closely  the  clinical 
course  of  these  cases,  we  have  already  noticed  that  they  usually  only 
occur  in  old  persons,  and  that  the  local  disease  progresses  slowly ; 
some  cases  last  seven  or  eight  years  before  half  of  one  breast  is  atro- 
phied. The  general  health  meantime  remains  unimpaired.  The 
lymphatic  glands  occasionally  participate  in  the  disease  ;  in  this  case 
the  process  goes  on  just  as  in  the  mamma  ;  there  is  very  little  enlarge- 
ment, but  much  hardening  and  cicatricial  shrinldng.  The  more  raj)- 
idly  and  completely  the  new  formation  atrophies,  and  the  more  slowly 
the  process  extends,  the  more  injurious  it  is ;  after  extirpation  or 
cauterization  this  variety  of  cancer  does  not  recur  for  a  long  time,  if  it 
does  so  at  all ;  metastatic  tumors  are  rare ;  in  the  main,  the  infiltra- 
tion does  not  appear  to  differ  much,  anatomically,  from  that  in  chronic 
hepatitis  and  nephritis  with  subsequent  shrinking ;  why,  then,  distin- 
guish this  scirrhus  fi'om  those  processes  ?  Wernher  terms  this  disease 
of  the  mamma  cirrhosis  onwnmce.  I  recognize  perfectly  the  justice 
of  doubting  the  carcinomatous  nature  of  some  cases  of  scirrhous  mam 


CARCINOMATA.  787 

mse,  but  must  still  insist  upon  classing  them  generally  among  cancers, 
for  the  following  reasons  :  As  you  already  know,  among  tumors  the 
process  of  contracting  is  pecvdiar  to  cancers ;  moreover,  the  contract- 
ing cancer  is  not  unfrequently  combined  with  ordinary  cancer ;  indeed, 
it  is  more  common  for  more  or  less  cancerous  proliferation  to  go  on 
along  with  the  scirrhous  affection,  while  the  wholly-cicatrizing  cancera 
are  relatively  rare.  This  combination,  which  occurs  neither  in  cirrho- 
sis of  the  liver  nor  of  the  kidney,  speaks  entirely  for  the  near  relation 
of  this  cicatrizing  new  formation  to  cancer ;  in  these  combined  cases 
there  are  also  local  recurrences  of  the  extirpated  tumors,  tumors  of 
the  lymphatic  glands,  and  even  metastatic  cancers  of  internal  organs. 
In  the  tumors  that  consist  chiefly  of  cicatricial  substance,  and  hence 
are  to  be  classed  rather  with  scirrhus  than  with  ordinary  cancer,  we 
may  give  a  tolerable  prognosis,  inasmuch  as  the  disease  always  runs 
a  slow  course. 

We  now  mention  another  form  of  cancer  of  the  breast  which  also 
begins  as  an  induration  in  the  gland,  but  soon  extends  to  the  skin, 
and  there,  in  the  form  of  small  nodules,  quickly  spreads  over  the 
whole  skin  of  the  anterior  wall  of  the  thorax ;  the  second  breast  is 
often  affected  the  same  way.  This  cancer  lenticularis  (Schuh),  squirrhe 
pustuleux  ou  dissemine  (  Velpeau),  appears  partly  as  a  primary,  partly 
as  a  recurring  form  after  extirpation  of  hard  cancer  of  the  breast,  and 
not  exactly  in  old  women.  This  small  nodular  (we  might  almost  say 
tuberculated)  form  may,  by  confluence  and  contraction,  lead  to  actual 
lacing  in  of  the  skin  of  the  thorax  from  the  front  and  sides  (cancer  en 
cuirasse,  Velpeau) ;  the  course  is  slow,  the  tendency  to  metastases 
to  internal  organs  is  not  great,  but  the  prognosis  is  very  bad,  because 
every  attempt  to  prevent  local  extension  by  operation  is  in  vain. 


3.  Mucous  membranes  with  cylindrical  epithelium.  Most  cancers 
that  form  in  the  nose  and  antrum  Highmori,  and  gradually  extend  to 
the  upper  jaw,  ethmoid  and  sphenoid  bone,  as  well  as  into  the  orbit, 
start  from  the  mucous  membranes  of  the  nose  and  antrum  Highmori. 
The  ciliated  or  non-ciliated  epithelium  of  these  membranes  only  ex- 
tends to  the  openings  of  the  mucous  glands,  and  even  in  the  develop- 
ment of  cancers  of  the  glands  at  these  points  rarely  grows  into  the 
deeper  parts.  It  appears  to  be  rather  the  acmi  of  the  gland  itself 
from  which  the  proliferation  proceeds,  for  these  cancers  appear  to  be 
mostly  composed  of  acini  or  tubuli,  which  have  small  or  larger  round 
cells,  rarely  cylinder-cells,  still  more  rarely  ciUated  cells.  The  shape  of 
the  newly-formed  acini  and  their  size  here  differ  enormously,  but  often 


783 


TUMORS. 


are  so  distinci,  so  normal,  that  they  may  be  mistaken  for  normal  mu- 
cous glands ;  to  render  this  deception  complete,  it  not  unfrequently 
happens  that  the  newly-formed  acini  secrete  mucus,  which  remains 
and  collects  in  them.     If  the  secretion  from  many  acini  be  retained, 


Pio.  168. 


Cancer  of  tiie  raucous  t,'Iau(ls  lVo:;i  tlic  interior  ol'tlic  nose.    Mainlined  200  diameters. 


the  form  of  the  neoplastic  glandular  acini  bo  perfectly  round,  and  the 
interstitial  connective  tissue  be  but  slightly  developed,  the  hardened, 
fine  sections  of  such  a  tumor  may  very  much  resemble  tissue  of  the 
thyroid  gland.  The  interstitial  tissue  is  usually  very  soft  in  these 
tumors  j  as  in  the  corresponding  mucous  membranes  themselves,  it 
may  be  almost  mucous.  Interstitial  papillary  proliferations  of  hyaline 
vascular  connective  tissue  (cylindroma)  also  occasionally  occur  here. 

These  tumors  are  always  very  soft,  white,  medullary,  or  gelatinous, 
except  when  very  vascular  ;  then  they  are  dark  red.  The  bones  are 
destroyed  by  caries,  without  a  trace  of  reactive  bony  new  formation 
or  osteophytes.  The  appearance  and  clinical  course  of  these  tumors 
are  somewhat  peculiar,  differing  from  other  carcinomata.  They  occur 
any  time  after  the  twentieth  year,  grow  rapidly,  and  project  sometimes 
through  the  nares,  again  through  the  cheeks  or  inner  can  thus  of  the 
eye ;  they  are  occasionally  very  sharply  bounded  or  encapsulated, 
which  may  be  known  by  palpation,  and   proved  on  operation  ;  some> 


CARCINOMATA. 


789 


times  they  are  more  diffusely  spread  in  the  upper  jaw.  In  these  mu- 
cous-gland cancers  of  the  face  I  have  never  seen  infection  of  the  lym- 
phatic glands,  and  am  convinced  that  these  patients  could  be  saved  by 
an  early  complete  operation.  In  all  the  patients  that  I  have  operated  on, 
I  have  never  been  satisfied  that  the  tumor  was  entirely  removed  by  the 
operation  ;  it  always  projected  too  far  posteriorly  or  upward  to  per- 
mit the  operation  to  be  completed  with  safety.  Hence,  I  usually  wit- 
nessed local  recurrences,  which  proved  fatal  by  marasmus  or  pressure 
on  the  brain,  or  else  the  patient  died  from  the  extent  of  the  operation ; 
in  none  of  the  cases  examined  post  mortem  did  I  find  internal  tumors. 
In  the  stomach  gland-cancers  are  frequent,  especially  with  mucous 
softening  (gelatinous  cancer),  and  secondary  cancer  of  the  liver  ;  can- 
cer of  the  duodenum  is  very  rare ;  of  the  parts  of  the  intestinal  canal 
attacked  by  this  disease  we  are  only  interested  in  the  cancers  of  tlie 
rectum.  These  are  almost  exclusively  gland-cancers,  and  the  prolifer- 
ation proceeds  from  the  large  glands  of  the  large  intestine,  whic'.i 
groAv  in  the  shape  of  tortuous  and  branched  tubes ;  the  calibre  of  the 
gland  is  often  maintained,  and  they  fill  with  mucus,  and  the  cylinder- 
cells  xnay  maintain  their  form  and  become  very  large.     The  intersti- 

FiG.  163. 


AtiOToid  CBr.cer  of  the  rectum     Magnified  2«)U  di.itncters 


t'al  connective  tissue  is  stnnvn  with  small,  round  cells,  sometimes 
softened,  and  often  very  vascular.  Usually  at  first  the  muscular  coat 
of  the  intestine  is  hypertrophied ;  subsequently  it  also  is  affected  bj 
Uie  ulceration,  which  generally  begins  earlv. 


790  TUMORS. 

As  the  first  symptoms  of  cancer  of  the  rectum  are  usually  consti- 
pation, discharge  of  mucus,  and  slight  hfemorrhage,  these  patients 
are  mostly  treated  for  some  time  as  if  suffering  from  haemorrhoids,  be- 
fore the  diagnosis  is  made  by  digital  examination.  Induration  and 
nodular  infiltration,  leaf-like  proliferations  commencing  close  above  the 
sphincter  ani,  soon  extend  to  the  whole  circumference  of  the  mucous 
membrane,  so  that  a  thick,  prominent  ring,  a  stricture  of  variable 
length,  may  be  felt.  This  new  formation  can  only  be  removed  by  ex- 
tirpating the  rectum.  When  the  rectum  is  taken  out,  we  generally 
find  an  ulcer  with  elevated  edges  and  indurated  base,  and  the  parts 
around  infiltrated  with  medullary  substance;  at  some  points  also 
there  are  cicatricial  contractions.  The  inguinal  and  retroperitoneal 
glands  are  affected  rarely  and  late  in  the  disease.  Tlie  patients  gen- 
erally die  from  the  stricture  of  the  intestine,  from  marasmus,  due  to 
haemorrhages,  and  putrefaction  of  the  cancerous  tissue. 

Occasionally  also  cancers,  composed  mostly  of  cylindrical  epithe- 
liima,  start  from  the  pars  cervicalis  uteri.  These  first  attack  the 
uterus,  then  the  surrounding  parts,  and  lastly  infect  and  infiltrate  the 
retroperitoneal  glands  ;  they  combine  with  flat  epithelial  cancers,  and 
do  not  differ  from  these  in  their  course. 

4.  Lachrymal,  salivary,  and  prostatic  glands.  The  same  kind  of 
tumors  grow  from  the  lachrymal  glands  that  we  have  already  de- 
scribed as  growing  from  the  nasal  mucous  membrane,  acinous  glan- 
dular new  formations,  with  soft,  occasionally  mucous,  or  even  papillary 
hyaline  interstitial  connective  tissue  (cylindroma).  They  develop 
about  the  age  of  puberty,  and  are  characterized  by  great  tendency 
to  local  recurrence.  All  the  cases  of  this  nature  that  I  have  known 
of  finally  died  from  the  local  recurrence;  it  might  be  not  for  sev- 
eral vears ;  neither  the  lymphatic  glands  nor  internal  organs  were 
affected.  O.  Becker  has  described  tumors  of  this  sort,  in  which  most 
of  the  fflandular  acini  contained  a  certain  quantity  of  mucous  secre- 
tion, as  also  occurs  more  especially  m  the  glandular  cancer  of  the 
rectum. 

The  salivary  glands  may  also  be  the  seat  of  glandular  cancer,  but 
they  do  not  come  till  old  age ;  then,  however,  they  grow  rapidly,  and 
not  unfrequently  resemble  chronic  inflammation.  The  newly-formed 
acini  are  often  more  tubular  than  acinous ;  epithelial  pearls  occur  on 
the  ends  of  the  tubuli,  covered  with  cylinder-cells.  These  patients 
usually  succumb  to  the  ulceration  of  the  tumor  and  the  general  ma- 
rasmus ;  internal  carcinoma  is  a  rare  sequent. 

In  the  prostatic  gland  I  have  seen  glandular  cancer  a  few  times ; 
it  was  very  soft,  and  in  one  case  where  partly  extirpated  it  was  very 
vascular,  and  of  acinous  structure.     From   the   excellent   statistical 


CARCINOMATA.  79  j 

rork  on  malignant  new  formations  in  the  prostate  by  0.  TFyss,  it  ap 
pears  that,  in  almost  every  case,  these  carcinomata  also  prove  fatal 
solely  from  the  local  symptoms.  Lymphatic  glands  and  adjacent 
parts  become  infected ;  there  are  very  rarely  secondary  cancers  of  in- 
ternal organs. 

5.  Thyroid  gland  and  ovary.  I  place  these  two  organs  together, 
as  they  both  originate  from  true  glandular  epitheHum,  and  both  con- 
tain folUcles,  formed  by  choking  off  of  glandular  canaliculi.  In  can- 
cerous disease  both  organs  fall  back  into  the  embryonal  type,  i.  e.,  the 
follicles  grow  again  to  tubes  and  canaliculi,  from  which  again  new 
follicles  are  developed;  but  some  of  these  carcinomata,  which  are 
rare,  consist  entirely  of  cell-canalicuh,  without  any  development  of 
follicles.  Yoimg  persons,  as  well  as  old  ones,  may  be  attacked  by 
this  form  of  cancer.  Its  course  is  usually  rapid,  for  the  cancers  of 
the  thyroid  grow  into  the  windpipe  or  close  it  by  pressure,  while  the 
ovarian  tumors  are  characterized  by  their  enormous  growth  and  rapid 
adhesions  with  the  surrounding  parts,  and  by  the  speedy  development 
of  ascites  prove  dangerous. 

From  variations  in  their  course  and  anatomical  structure  we  must 
separate  the  different  forms  of  carcinoma ;  we  may  consider  their 
treatment  together.  Treatment  of  the  carcinomatous  dyscrasia  (ca]> 
cinosis)  is  usually  regarded  as  apartie  hontevse  of  medicine.  I  can- 
not admit  this.  It  is  true  we  cannot  cure  the  disease ;  but  is  not  this 
also  true  of  many  other  acute  and  chronic  diseases  ?  Can  we  arrest 
a  cold  in  the  head  at  any  stage  ?  Can  we  check  the  course  of  the 
acute  exanthema  or  typhus  ?  Can  we  cure  tuberculosis  ?  Certainly 
not ;  in  all  these  cases,  as  in  many  others,  the  disease  runs  its  typical 
course ;  we  give  little  medicine,  at  least  we  avoid  all  heroic  reme- 
dies. In  carcinosis  our  therapeutic  impotence  only  appears  so  great 
because  the  disease  almost  ahvays  proves  fatal,  and  we  can  do  nothing 
to  oppose  its  course ;  iu  fact,  oiu*  treatment  is  as  ineflficacious  in 
coryza  as  in  carcinosis ;  but  the  former  is  not  a  fatal  disease,  hence  no 
special  demand  is  made  on  the  physician.  We  have  become  accus- 
tomed to  failing  to  cure  cold  in  the  head ;  we  must  grow  accustomed 
to  the  course  of  cancerous  as  to  that  of  some  other  diseases ;  this 
will  not  interfere  with  our  sympathy  for  these  poor  patients,  nor  must 
it  prevent  our  striving  for  increased  knowledge  and  improved  treat- 
ment  of  the  disease.  I  think  that  much  may  yet  be  attained  in  this 
direction. 

The  indications  for  treatment  are  to  remove  the  cancerous  tumor 
as  soon  as  possible,  so  as  to  avoid  infection,  or  at  least  obstruct  its 
course,  and  thus  diminish  the  evils  accompanying  it. 


792  TUMORS 

As  long  as  cancer  has  been  known,  remedies  for  it  have  been 
sought ;  there  is  no  active  medicine,  no  form  of  dietetics,  or  mineral 
springs,  that  have  not  been  recommended  for  cancer,  and,  to  some  ex- 
tent, actually  believed  in.  I  should  have  to  root  up  the  entire  old 
and  new  materia  raedica  if  I  would  tell  you  of  every  thing  that  has 
been  thought  and  written  on  this  subject.  Like  all  incurable  dis- 
eases, carcinosis  also  has  been  a  wrestling-place  for  the  charlatan,  and 
even  of  late  years  Italians  and  Americans  have  claimed  to  cure  the 
disease  by  special  nostrums.  Unfortunately,  all  these  are  deceptions, 
or  at  least  what  part  of  it  is  true  has  been  long  known. 

Unfortunately,  the  etiology  of  cancer  gives  no  clew  to  treatment ; 
we  know  too  little  of  the  causes  why  certain  tumors  are  so  infectious, 
while  others  are  not  so.  A  blow,  kick,  etc.,  may  occasionally  induce 
an  outbreak  of  the  disease  in  some  few  cases,  but  cannot  excite  the 
predisposition  to  cancer.  In  some  cases  inheritance  of  the  disease  is 
evident.  Care  and  anxiety  may  hasten  the  course  of  the  disease,  but 
do  not  induce  it.  All  this  is  of  no  avail  for  the  treatment.  There  is 
no  specific  for  carcinosis ;  but  by  this  we  do  not  mean  to  say  that 
all  internal  treatment  is  unnecessary  or  useless.  By  no  means.  Tlie 
disease  should  be  treated  internally  whenever  there  are  indications 
for  treatment,  or  any  symptoms  pointing  to  the  use  of  certain  reme- 
dies. As  anaemia  is  not  unfrequent  in  cancerous  patients,  iron  in  va- 
rious preparations,  or  chalybeate  mineral  waters,  may  be  employed. 
Occasionally,  in  persons  with  faulty  nutrition,  cod-liver  oil,  etc.,  as 
well  as  bitter  medicines,  prove  beneficial  by  aiding  digestion.  Very 
debilitating  treatment,  by  sweating,  purging,  mercurials,  etc.,  is  to 
be  avoided,  for  life  will  be  preserved  the  longer  the  more  the  strength 
is  maintained.  Among  the  mineral  springs,  the  active  ones,  such  as 
Aix-la-Chapelle,  "Wiesbaden,  Karlsbad,  Kreuznach,  and  Rherae,  are 
injurious ;  only  the  milder  indiflFerent  thermal  springs,  such  as  Ems, 
Gastein,  Wildbad ;  also,  milk  and  whey  cures,  strengthening  moun- 
tain air  may  be  recommended  without  injury,  if  their  use  seems  on 
other  accounts  desirable.  Residence  in  southern  climates  is  usually 
of  little  benefit  for  cancerous  patients.  Toward  the  end  of  life,  when 
debility  is  increasing,  a  strengthening,  easily-digested  diet  is  impor- 
tant ;  and  lastly,  as  the  pain  increases,  the  skilful  use  of  various  nar^ 
cotics  relieves  the  sufferings  and  death  of  the  patient.  The  disease 
of  internal  organs  may  offer  special  indications  to  which  I  shall  not 
here  refer.  Arsenic  has  been  frequently  tried,  and  with  apparent 
benefit  in  a  number  of  cases  ;  it  should  be  given  till  signs  of  its 
action  are  observed. 

As  regards  external  treatment,  the  first  thing  always  is  the  re- 
moval of  the  tumor,  if  this  is  admissible,  from  its  locality.    The  opera- 


CARCINOMATA.  793 

tion  may  be  done  Avith  the  knife  or  caustics;  the  ligature  or  6craseur 
can  scarcely  ever  be  employed  here  (the  latter,  perhaps,  answers  only 
in  amputating  the  penis  or  tongue).  But,  before  passing  to  the  choice 
of  either  of  these  methods,  we  must  consider  the  question,  whether  it 
is  advisable  to  operate  at  all,  even  if  it  can  be  done  easily  and  without 
danger  to  life,  for  the  views  of  experienced  surgeons  differ  on  this 
point.  Some  surgeons  never  operate  for  cancer.  They  assert  that 
the  operation  is  always  in  vain,  because  the  disease  recurs ;  if  the  re- 
curring tumors  be  operated  on,  new  recurrence  takes  place  the  sooner ; 
these  surgeons  even  assert  that,  the  more  we  operate  locally,  the 
sooner  secondary  lymphatic  tumors  and  metastatic  cancers  form,  the 
local  tumor  acting  as  a  sort  of  derivative  for  the  tumor-disease ;  that 
this  product  of  disease  cannot  be  removed  without  favoring  the  out- 
break of  the  disease  elsewhere ;  that,  if  we  nevertheless  wish  to  re- 
move the  tumor,  we  should  lead  the  morbid  juices  to  some  other  point, 
as  by  establishing  an  artificial  ulcer  by  means  of  a  fontanel  or  seton. 
Concerning  this  view,  which  comes  from  the  old  humoral  pathology, 
we  may  say  that  it  remains  unproved,  and  is  partly  also  disproved  by 
experience.  We  consider  it  as  demonstrable  by  daily  experience  that 
the  glandular  swellings  are  essentially  due  to  the  development  of  the 
primary  tumors ;  we  have  already  stated  out  belief  that  the  participa- 
tion of  the  l}Tnphatic  glands  in  carcinoma  is,  according  to  all  analogy, 
caused  by  local  contagion,  let  the  process  be  what  it  may.  When 
cases  occur  where,  after  removal  of  cancers  of  the  breast  or  lip,  swell- 
ings of  the  lymphatic  glands  appear,  though  previously  imperceptible, 
we  must  consider  that  the  commencement  of  the  disease  was  so  slight 
as  to  escape  observation. — How  far  the  existence  of  a  primary  and 
secondary  cancer  of  the  lymphatic  glands  influences  the  subsequent 
course  of  the  disease,  the  appearance  of  metastatic  tumors  and  general 
cachexia,  is  a  question  which  cannot  be  answered,  because  the  disease 
does  not  run  its  course  in  a  regular  time ;  if  it  did,  we  might  form  a 
rule  as  to  the  advisability  of  operating,  by  comparing  cases  that  were 
operated  on  with  those  that  were  not.  Approximate  results  might 
be  attained  by  classing  together  cases  that  were  alike  in  age,  consti- 
tution, variety  of  the  tumor,  etc. ;  but,  as  the  accurate  distinction  of 
the  varieties  of  carcinomata,  and  consequently  an  exact  arrangement 
of  the  cases,  has  only  lately  been  attained,  and  even  now  is  not  gener- 
ally known,  we  cannot  at  present  expect  much  in  this  direction ;  in- 
dividual observations  rarely  suffice  for  definite  conclusions.  Tlie  ex- 
perience from  carcinoma  of  the  face,  that  the  most  extensive  disease 
of  the  lymphatic  glands  is  very  rarely  accompanied  by  metastatic 
tumors,  strongly  favors  the  belief  that  the  disease  is  not  made  more 
.  active  bv  these  strongly-developed  local  tumors,  and  that  carcinomata 


794  TUMORS. 

of  the  lymphatic  glands  do  not  increase  the  predisposition  to  mettist* 
tic  tumors. — In  reply  to  the  question,  whether  carcinoma  should  eve; 
be  operated  on,  we  may  say  that  operation  probably  has  no  direct  in- 
fluence on  the  diathesis,  and  that  the  operation,  if  done  at  all,  must 
be  done  for  other  reasons.  We  said  intentionally  that  the  operation 
has  no  direct  influence  on  the  course  of  the  disease,  but  we  think  il 
has  an  indirect  influence,  as  the  tumor  induces  other  causes  of  disease ; 
the  weakness,  anaemia,  and  disturbance  of  nutrition  caused  by  the  sup- 
puration and  pain  from  a  cancerous  tumor,  perhaps  also  the  constantly 
gnawing  care  with  the  ever-recurring  reflection  on  the  incurable  nature 
of  their  disease,  are  factors  which  may  well  hasten  the  course  of  the 
malady.  Under  some  circumstances  I  consider  it  the  duty  of  the 
physician  to  deceive  the  patient  about  the  incurability  of  this  disease, 
v/^hether  he  considers  an  operation  as  possible  or  not;  where  tlie 
physician  cannot  aid  the  patient,  he  should  alleviate  his  sufi'erings, 
mental  as  well  as  physical.  Few  persons  have  the  quiet  of  mind,  res- 
ignation, firmness,  or  whatever  you  choose  to  call  it,  to  enjoy  what 
remains  of  life,  if  they  know  they  have  an  incurable  disease.  Although 
perhaps  externally  quiet,  patients  will  thank  you  little  for  confirming 
what  they  may  have  feared.  On  this  point  you  will  have  many  trials, 
and  I  must  leave  you  in  each  case  to  do  whatever  is  dictated  by  your 
personal  shrewdness,  knowledge  of  men,  and  your  feelings. — Although 
we  may  not  get  rid  of  the  diathesis  by  the  operation,  as  when,  having 
removed  a  diseased  portion  of  breast,  we  fail  to  prevent  new  nodules 
forming  in  the  remaining  portion  which  was  previously  healthy,  or  in 
the  other  healthy  breast  (regional  recurrence),  soon  after  the  cicatrix 
has  healed,  still  by  the  early  removal  of  the  primary  tumor  we  may 
prevent  the  neighboring  glands,  or  the  adjacent  portion  of  mamma,  from 
becoming  diseased.  Few  as  are  the  complete  recoveries  from  cancer 
of  the  breast  after  operation,  I  believe  they  will  grow  more  frequent 
when  the  family-doctor,  to  whom  they  are  generally  first  shown,  urges 
operation  earlier,  for  at  present  they  usually  let  the  best  time  for 
operation  slip  by,  and  the  women  do  not  consult  professed  surgeons, 
till  the  local  disease  and  the  affection  of  the  axillary  glands  are  so  far 
advanced  that  a  complete  operation  is  no  longer  practicable.  The 
favorable  results  from  early  extirpation  of  true  cancer  of  the  lip  should 
embolden  us  to  remove  other  cancerous  tumors  earl3%  If  it  has  hither- 
to rarely  been  possible  to  operate  on  cancers  early  and  completely, 
there  are  still  important  local  causes  which  indicate  even  late  opera- 
tions, to  prevent  as  long  as  possible  the  advance  of  the  tumor  to  parts 
where  the  disease  would  necessarily  destroy  Hfe.  Although  in  most 
cases  there  will  be  local  recurrence,  this  will  not  take  place  for  months, 
perhaps  for  a  yeai ,  meantime,  life  will  not  be  directly  endangered  \ 


CARCINOMATA 


795 


occasionally  also  it  is  a  question  of  saving  from  entire  destruction  cer- 
tain parts  of  the  face,  as  the  lips,  eyelids,  or  nose,  which  may  subse- 
quently be  replaced  by  a  plastic  operation.  It  would  be  very  unjust 
to  consider  such  operations  useless,  because  they  cannot  cure  the  dis- 
ease,  for  they  render  the  patient's  hfe  easier  and  aiore  agreable— if 
only  for  a  time,  still,  possibly,  for  the  greater  part  of  the  time  that  he 
yet  has  to  live.  We  might  be  very  glad,  if,  by  an  operation  or  other 
treatment,  we  could  temporarily  restore  to  the  pleasures  of  life  a 
patient  with  advanced  tuberculosis  of  the  lungs,  as  is  the  case  in  oper- 
ating for  some  cancerous  tumors.  In  short,  there  are  many  cases 
where  we  do  good  by  the  operation ;  very  often  I  should  consider  it 
wrong  to  refuse  to  operate. — We  see  other  cases,  however,  where  it 
is  more  difficult  to  decide.  In  slowly-progressing  cancers  of  the  breast, 
as  in  connective-tissue  cancers,  I  consider  an  operation,  which  is  free 
from  danger,  as  admissible,  but  not  necessary.  If  an  eyelid  be  de- 
stroyed, or  the  nose  partly  or  entirely  lost,  an  operation  is  advisable, 
in  the  first  case  to  protect  the  eyeball,  in  the  second  to  remove  the 
deformity,  and  the  rather  so,  because  in  these  slowly-progressing  flat 
cancers  of  the  face  frequently  there  is  no  local  recurrence ;  in  such 
cases  only  one  thing  would  prevent  my  operating,  viz.,  great  debihty 
or  advanced  age  of  the  patient ;  at  least  then  extensive  plastic  opera- 
tions are  no  longer  advisable ;  even  the  unavoidable  loss  of  blood,  and 
keeping  the  patient  in  bed  after  the  operation,  may  suffice  to  extin- 
guish the  feeble  vital  spark.  Then  comes  the  question  about  the  ad- 
missibility of  the  operation,  where  the  tumor  is  in  a  dangerous  loca- 
tion, when  an  operation  is  necessary  that  may  end  fatally,  or  at  least 
is  just  as  likely  to  end  fatally  as  to  result  in  cure.  Here  we  have  to 
drop  general  reflections,  and  consider  the  individual  cases ;  the  danger 
seen  in  an  operation  varies  greatly  with  the  experience  of  the  surgeon, 
and  the  individuality  of  the  patient ;  one  principle  we  should  adhere 
to :  only  to  operate  when  after  careful  examination  we  can  hope  to 
remove  all  of  the  diseased  part ;  a  half-operation,  leaving  behind  por 
tions  of  the  tumor,  should  never  be  done.  We  should  be  careful  to 
operate  only  in  healthy  tissue,  if  possible  a  centimetre  or  more  from 
the  perceptible  infiltration,  for  in  this  way  alone  can  we  be  certain 
of  removing  all  of  the  diseased  part.  Occasionally  in  desperate  cases 
we  may  prolong  life  by  a  bold  operation,  even  if  the  cancerous  tumor 
be  already  very  large,  but  generally  in  such  operations  we  shall  see 
more  patients  die  than  will  recover. 

We  have  now  to  criticise  the  caustics  chiefly  used  in  cancers.  In 
the  course  of  time  opinions  about  caustics  have  differed  greatly  ;  at 
times  they  were  greatly  preferred  to  the  knife,  again  they  were  en- 
tirely  thrown  aside.     The  views  of  most  surgeons  of  the  present  day 


796  TUMORS. 

as  well  as  my  own,  incline  to  the  latter  view.  I  decidedly  prefer  the 
operation  with  the  knife  or  scissors,  because  I  then  know  exactly  what 
T  remove  and  I  can  judge  more  certainly  if  all  the  diseased  part  has 
been  excised.  Hence,  I  regard  the  operative  removal  of  cancer  as 
well  as  of  other  tumors  to  be  preferable  as  a  rule.  But  where  there 
is  a  rule  there  are  exceptions.  In  very  old,  anaemic,  or  timid  patients, 
caustics  may  be  employed,  and,  if  the  treatment  be  continued  till  all 
the  diseased  portion  is  destroyed,  the  result  will  be  favorable.  Physio- 
logically caustics  would  have  some  advantages ;  for  it  is  supposable 
that  the  cauterizing  fluid  may  enter  the  finest  lymphatic  vessels,  and 
thus  more  certainly  destroy  the  local  disease.  But  this  does  not  oc- 
cur  readily,  because  the  tissue  with  which  the  caustic  comes  in  contact 
instantly  combines  with  it,  and  its  further  flow  is  thus  prevented. 
Formerly  it  was  asserted  that  recurrence  did  not  take  place  so 
soon  after  the  use  of  caustic  as  after  operation  with  the  knife,  but 
this  has  not  been  confirmed ;  hence  I  only  maintain  the  above  ex- 
ceptions. 

For  a  caustic  I  prefer  chloride  of  zinc  to  all  others  for  destroying 
cancers ;  you  may  use  it  as  paste  or  as  caustic  arrows.  If  it  is  a  sur- 
face you  wish  to  cauterize,  to  equal  parts  of  powdered  chloride  of 
zinc  and  flour  you  add  enough  water  to  make  a  paste,  which  you  apply 
to  the  surface.  If  you  desire  to  cauterize  more  deeply,  you  mix  one 
part  of  chloride  of  zinc  with  three  parts  of  flour  or  gum  and  some 
water,  and  let  them  form  a  cake  and  dry ;  this  may  readily  be  cut  up 
into  small  pointed  cylinders  half  a  centimetre  or  more  in  thickness ; 
with  a  lancet  you  make  an  opening  in  the  tumor  and  press  the  caus- 
tic arrow  into  it ;  you  repeat  tliis  operation  till  the  tumor  is  perforated 
with  arrows  at  about  three  quarters  of  an  inch  distance  from  each 
other.  In  four  or  five  hours  this  cauterization  is  follo\f  ed  by  moderate, 
often  by  very  severe  pain,  which  you  may  greatly  modify  by  giving 
a  subcutaneous  injection  of  morphine  directly  after  the  cauterization ; 
the  next  day  you  find  the  tumor  changed  to  a  white  slough.  This 
becomes  detached  after  five  or  six  days,  earlier  in  soft  tumors,  later  in 
hard  ones.  If  the  cauterization  has  extended  far  enough  into  the 
healthy  parts,  after  the  detachment  of  the  eschar  there  is  left  a  good 
granulating  wound,  which  soon  cicatrizes ;  if  the  carcinomatous  mass 
again  grows,  the  paste  or  arrows  should  be  again  applied,  etc. 

These  cauterizations  are  occasionally  very  painful  and  uncertain 
as  regards  the  extension  of  the  caustic,  but  they  occasionally  are 
advantageous.  Other  celebrated  caustics  are  Vienna  paste,  arsenio 
paste,  butter  of  antimony,  chloride  of  gold,  etc. ;  iodide  of  potash, 
chromic  acid,  concentrated  solutions  of  chloride  of  zinc,  fuming  nitric 
acid,  sulphuric  acid,  etc.,  are  less  employed. 


CARCINOMATA.  797 

Now  a  few  words  of  advice  about  the  local  treatment  of  cancer- 
ous ulcers  which  are  not,  or  at  least  are  no  longer,  suited  for  opera- 
tion. In  some  of  these  cases  the  proliferation  of  the  cancerous  mass 
from  the  wound  is  enormous,  and  it  often  annoys  and  debilitates  the 
patient ;  here  we  may  make  partial  cauterizations  or  employ  the  hot 
iron ;  by  the  palliative  destruction  of  the  proliferating  mass,  we  occa- 
sionally attain  tolerably  good  results.  The  chief  indication  for  treatr 
ment  in  these  patients  is  suppuration  of  the  ulcer,  which  is  occasionally 
horridly  fetid,  and  sometimes  the  pain.  For  preventing  the  disagree- 
able secretion,  the  hot  iron  is  a  good  remedy ;  the  smell  may  be  les- 
sened by  compresses  wet  with  chlorine-water  or  purified  acetic  acid, 
creosote,  carbolic  acid,  permanganate  of  potash,  sprinkling  with  pow- 
dered charcoal.  The  latter  readily  absorbs  gases,  as  you  know  from 
chemistry,  and  is  here  an  excellent  remedy ;  unfortunately,  it  dirties 
the  wound,  so  that  we  abstain  from  its  frequent  use.  For  the  pain  of 
carcinomatous  ulcers,  narcotics  have  been  applied  locally,  as  by  sprink- 
ling on  powdered  opium ;  but,  when  injected  subcutaneously  or  given 
internally,  the  narcotics  act  more  certainly ;  hence  at  last  we  always 
resort  to  morphine  for  these  poor  patients.  I  particularly  enjoin  on 
you  patience  in  caring  for  and  alleviating  the  sufferings  of  these  unfor- 
tunates ;  it  is  indeed  sad  for  the  physician  to  be  able  to  do  so  little 
good  in  these  cases,  but  still  you  must  not  abandon  them. 

[From  recent  statistical  tables  about  mammary  cancer,  it  is  evi- 
dent that  life  is  prolonged  by  operation  ;  but  there  is  no  doubt 
that  the  disease  may  also  be  entirely  cured  even  when  infiltrated 
lymphatic  glands  have  to  be  removed,  or  it  has  to  be  repeated  two 
or  three  times  on  account  of  relapses.  I  have  had  cases  where  there 
was  no  recurrence  three  years  after  ;  in  almost  all  cases  where  there 
is  recurrence  locally,  or  in  the  lymphatic  glands,  it  takes  place 
within  a  year  ;  if  only  a  small  proportion  of  cases  is  thus  cured, 
operation  is  justitiable.  In  most  cases  there  is  recurrence  after 
removal,  because  it  is  done  too  late.  Some  of  these  cases  are  oper- 
ated, without  expectation  of  cure,  but  to  relieve  suffering  or  escape 
local  danger.  In  operating,  some  surgeons  always  remove  the  ad- 
jacent glands,  which  are  apt  to  be  implicated,  whether  they  are  at 
the  time  diseased  or  not.  Of  late,  carcinomata  of  certain  regions 
are  removed  by  the  galvano-  or  thermo-cautery.  These  are  not 
strictly  cauterizations,  as  the  neoplasia  is  not  cauterized,  but  the  re- 
moval is  made  through  healthy  tissue.  Langenbeck  recommends 
the  thermo-cautery  in  removing  the  tongue,  as  it  is  a  convenient, 
bloodless  operation,  and  after  the  diseased  tissue  is  removed  the 
healthy  parts  are  destroyed  for  some  distance,  thus  increasing  the 
probabilities  of  a  radical  operation. 


798  TUMORS. 

A  most  important  question  theoretically  and  practically  is  the 
relation  of  the  lymphatic  glands  to  the  primary  cancer  ;  we  may 
find  in  its  vicinity  glands  scarcely  as  large  as  a  pea,  but  having  mi- 
croscopically distinct  signs  of  cancerous  degeneration.  If  the  infil- 
trated glands  are  larger,  we  may  often  feel  a  hard  string  from  the 
gland  to  the  tumor.  Formerly,  this  was  considered  as  the  throm- 
bosed lymph-vessel ;  now  we  know  it  contains  lymph  and  blood-ves- 
sels and  connective  tissue,  all  more  or  less  implicated  in  the  disease. 
The  glands  themselves  at  first  contain  disseminated  foci  of  carcinoma 
tissue,  later  they  change  to  a  cancerous  tumor  ;  the  capsule  is  rup- 
tured, the  glands  melt  together  and  unite  with  the  parts  around  ; 
adhesions  with  large  vessels,  as  the  axillaiy  vein,  are  very  impor- 
tant. Macroscopic  and  microscopic  examinations  show  the  type 
and  structure  of  the  lymphatic  tumors  to  be  the  same  as  those  of 
the  primary  disease  ;  this  is  true  of  all  the  carcinomata  that  induce 
infection  of  the  lymphatics.  This  correspondence  in  structure  is 
important  in  explaining  the  mode  of  infection  ;  we  have  said  there 
were  two  explanations  given :  some  pathologists  suppose  that  cel- 
lular elements  of  the  primary  tumor  pass  by  the  blood  and  lymph 
circulation  to  various  points,  and  there  grow  to  secondary  tumors  ; 
of  course,  this  is  supported  by  the  adherents  of  the  germ-layer 
theory  ;  for  development  of  carcinoma  in  a  lymphatic  gland,  where 
there  is  no  true  epithelium,  could  only  come  from  the  transfer  of 
cancer-cells.  Against  this  hypothesis,  Virchow's  infection  theoiy 
has  lately  received  some  new  support.  From  our  present  knowl- 
edge, this  alone  is  able  to  explain  the  facts.  Just  as  I  consider  the 
primary  development  of  cancer-cells  from  elements  of  connective 
tissue  of  the  muscles,  from  endothelium  of  the  lymph  and  blood- 
vessels, etc.,  proved,  I  also  believe  that  the  secondary  disease  of  the 
lymphatic  glands  comes  by  metamorphosis  of  the  cellular  elements 
of  the  glands  themselves,  especially  of  the  lymph-granules,  cells  of 
the  reticulum,  walls  of  the  vessels,  etc.,  and  that  the  tumors  are  in- 
duced by  true  infection  by  seed  from  the  primary  tumor,  probably 
carried  there  by  the  current  in  the  lymphatics. 

Recently  Gussenhauer  has  published  something  on  this  subject. 
He  believes  the  bearers  of  the  seed  to  be  small  round,  pale,  or,  in 
melanoma,  pigmented  granules,  which  occur  in  the  protoplasm,  nu- 
clei of  the  lymph-cells,  endothelium,  walls  of  the  vessels,  and  also 
free  in  the  lymph-channels.  These  he  calls  "  corpuscular  elements," 
and  says  that  from  the  primary  tumor  they  pass  into  the  glands, 
from  which  they  enter  all  sorts  of  cells ;  their  presence  indicates 
the  first  stage  of  gland-infection  by  a  tumor,  whether  sarcoma  or 
carcinoma.     Cells  of  the  gland  that  have  taken  up  these  corpuscular 


CARCINOMATA.  799 

elements  at  once  begin  to  proliferate  and  approach  the  type  of  cells 
of  the  infecting  tumor  ;  so  nodules  form  just  like  the  primitive 
growth.  Gussenbauer  regards  these  elements  as  "  fertilizing  germs, 
which,  coming  from  the  infectious  tumor,  carry  certain  qualities  to 
the  tissue-cells  of  the  glands,  so  that  they  no  longer  bear  the  type 
of  the  mother-tissue,  but  that  of  the  infecting  tumor." 

Gussenbauer  does  not  go  more  accurately  into  the  nature  and 
formation  of  these  "-fertilizing  germs,"  nor  could  he  discover  dif- 
ferences between  the  germs  of  different  kinds  of  tumor.  The  es- 
sential part  of  his  theory  is,  that  the  corpuscular  elements,  coming 
from  the  tumor,  do  not  themselves  form  tumor-cells,  but  that,  by 
entering  the  lymphatic  glands,  they  excite  these  to  heteroplastic 
production,  or  are  truly  infecting.  Passage  of  tumor-cells  from 
the  primary  tumor  into  the  lymphatics,  even  if  proved,  would  be 
much  less  important  than  this  infection. 

When  cancer  attacks  bone,  it  is  eaten  away,  but  not  as  by  press- 
ure from  other  tumors  ;  there  is  a  peculiar  infiltration  with  tumor- 
cells. 

In  suitable  preparations,  in  cross-sections,  the  Haversian  canals 
appear  filled  by  a  mass  of  cells  around  the  vessels,  probably  from 
the  wandering  cells ;  there  is  also  proliferation  of  the  bone-cor- 
puscles ;  the  shape  of  the  bone  is  preserved  even  when  the  chalky 
salts  have  been  absorbed  ;  in  the  centre  there  are  heaps  of  cells  in 
concentric  rings,  separated  by  basement  substance.  Gradually  the 
elements  preponderate,  the  bone  disappears,  but  the  anatomical 
structure  remains.  According  to  the  epithelial  theory  of  Thiersch 
and  Waldeyer,  these  are  only  reaction  appearances  induced  by  the 
encroaching  cancerous  infiltration  ;  the  cells  forming  around  the 
vessels  in  the  Haversian  canals  and  from  the  bone-corpuscles  seem 
to  me  to  be  young  cancer-cells,  and  the  arrangement  of  the  tumor 
elements  in  the  structure  of  bone  seems  a  proof  of  their  being 
formed  by  proliferation  of  previously-formed  bone-cells.] 


BEIEF  EEMARKS  ABOUT  THE  CLINICAL  DIAGNOSIS  OF  TUMORS. 

I  cannot  take  it  amiss  if  you  are  at  first  somewhat  confused  by 
what  I  have  said  to  you  about  tumors  ;  if  it  will  encourage  you,  I  may 
acknowledge  that  formerly  it  was  the  same  with  me  Avhen  I  was  in 
your  present  position.  Only  long  study  and  practice  in  the  differen- 
tial diagnosis  of  tumors,  for  which  there  is  opportunity  in  the  clinic, 
render  it  possible  to  attain  any  certainty  on  this  difticult  point.    The 


800  TUMORS. 

consistence  of  the  tumor  and  its  appearance,  its  relation  to  the  parts 
around,  its  locality,  the  rapidity  of  its  growth,  and  the  age  of  the  pa- 
tient, are  the  points  from  which  we  start  in  judging  ;  sometimes  one, 
sometimes  another,  of  these  points  gives  the  decision.    Let  us  take  an 
example:  A  man  about  fifty  years  old  comes  to  you,  ruddy  and  strong 
for  his  age  ;  for  many  years  he  has  had  a  tumor  on  the  back,  which 
formerly  gave  him  no  trouble  ;  it  has  only  been  inconvenient  since  it 
has  reached  nearly  the  size  of  a  child's  head.    The  tumor  is  elastic,  soft 
but  not  tense  or  fluctuating,  movable  under  the  skin ;  the  latter  is  un- 
changed ;  there  has  never  been  pain  in  the  tumor,  nor  is  any  caused 
by  the  examination.     In  this  case  the  diagnosis  is  very  easy  :  from 
I  lie  location,  from  its  seat  in  the  connective  tissue,  its  slow,  painless 
growth,  etc.,  it  can  scarcely  be  any  thing  but  a  lipoma,  or  possibly  a 
soft  connective-tissue  tumor ;  but  the  former  is  most  probable.     Let 
us  take  another  case  :  A  woman  with  a  tumor  of  the  breast  comes  to 
you ;  this  tumor  is  hard,  nodular,  as  large  as  an  apple ;  over  the  sur- 
face the  skin   is  retracted  at  spots,  and  is  adherent  to  the  tumor. 
From  time  to  time  there  has  been   piercing  pain,  the  tumor  is  sensi- 
tive to   pressure,   the   axillary  glands    on  that  side   feel   hard.      The 
woman  is  forty-five  years  old,  well  nourished,  and  looks  healthy.    Here 
also  the  diagnosis  is  easy ;  it  is  a  carcinoma :  1.  Because  the  patient 
is  at  the  age  when  cancerous  tumors  of  the  breast  are  most  frequent, 
while  adenoma  and  sarcoma  usually  occur  earlier ;  2.  The  consistence 
might  point  to  fibroma,  but  this  very  rarely  occm^  in  the  breast,  and 
the  swelling  of  the  lymphatic  glands  speaks  against  this  view,  and  in 
favor  of  carcinoma ;  3.  Carcinomata  are  painful,  as  this  case  is,  while 
sarcomata  and  fibromata  are  not  so,  usually.     We  might  give  further 
reasons  for  the  diagnosis,  but  these  will  sufiice.     Let  us  take  a  third 
case :  A  boy  ten  years  old  has  had  for  two  years  a  slowly-enlarging, 
moderately  painful  swelling  of  the  middle  part  of  the  lower  jaw  ;  at 
this  point  the  teeth  have  fallen  out  without  being  diseased;  the  en- 
largement of  the  bone  is  evenly  round,  and  reaches  from  the  first  back 
tooth  of  one  side  to  the  similar  point  on  the  other ;  below,  it  is  hard 
as  bone,  above  (in  the  mouth)  it  is  covered  by  mucous  membrane,  is 
firm  and  elastic.     Can  this  bony  swelling  be  the  result  of  chronic  in- 
flammation, of  a  caries  or  necrosis  ?    This  is  not  probable:  1.  Because 
the  pain  has  always  been  slight;  2.  Because  there  has  been  no  sup- 
puration, which  would  scarcely  fail  to  occur  in  an  inflammation  of  the 
jaw  that  had  lasted  two  years ;   3.  Because   the  swelling  is   more 
bounded  and  regular  than  it   is  apt  to  be  in  bony  deposits  in  caries 
and  necrosis ;  4.  Because,  at  the  patient's  age,  osseous  inflammation 
in  the  lower  jaw  is  not  apt  to  occur  unless  from  phosphoreous  poison- 
ing, which  has  not  occurred  here.     Hence  this  is  a  case  of  tumor ;  is 


CLINICAL   DIAGNOSIS   OF   TUJIORS.  801 

it  an  osteoma  ?  The  part  projecting  into  the  mouth  is  too  soft  for 
this  ;  we  may  pass  a  line  needle  into  the  tumor  from  above.  Is  it 
a  chondroma  ?  Consistence,  form,  mode  of  growth,  and  age  of  the 
patient,  agree  with  this  view,  but  the  locality  does  not ;  chondro- 
mata  in  the  middle  of  the  lower  jaw  at  this  age  are  very  rare.  It 
is  a  central  osteo-sarcoma,  probably  a  giant-celled  sarcoma  ;  all  the 
symptoms  speak  in  favor  of  this  idea,  and  you  know  that  these 
tumors  are  frequent'  in  the  lower  jaw  during  youth.  I  say  you 
know — I  might  better  say  you  will  gradually  learn  ;  and  I  can  only 
advise  you,  whenever  you  have  examined  a  patient  with  a  tumor  at 
the  clinic,  to  read  about  it  when  you  go  home,  and  to  compare  the 
individual  case  with  the  general  characteristics  of  the  tumors  that  I 
have  given  you.  When  you  have  done  this  for  a  time,  and  in  the 
course  on  pathological  histology,  under  the  instruction  of  j^our 
teacher,  have  examined  many  tumors,  you  will  obtain  a  better  idea 
of  them,  and  will  have  all  their  peculiarities  painted  on  your 
memory. 

52 


CHAPTER   XXII. 

AMPUTATIONS,  EXABTICULATIONS,  AND  BESEC- 

TIONS. 


LECTURE    LI. 

Importance  and  Significance  of  these  Operations. — Amputations  and  Exarticulations. — 
Indications. — Methods. — After-Treatment. — Pro<^i)osis. — Conical  Stumps. — Prothe- 
sis. — Historical  Remarks. — liesediom  of  Joints. — History. — Indications. — Methods. 
— After-Treatmeut. — Prognosis. 

Gentlemen  :  We  have  often  had  occasion  to  speak  of  amputa- 
tions and  resections  ;  so,  before  closing  these  lectures,  I  will  explain 
to  you  these  important  operations,  by  which  we  remove  limbs  or 
portions  of  limbs  which  are  so  diseased  that  we  cannot  restore  them 
to  health.  These  operations,  which  are  often  so  beneficial,  even  to 
saving  life,  are  sometimes  regarded  as  a  testimonium  paupertatis  of 
surgery  ;  for  cutting  off  diseased  parts  is  not  a  genuine  cure,  if  by 
cure  we  mean  by  our  skill  to  restore  to  its  normal  state  a  part  of  the 
body  which  has  been  changed  by  disea?e.  However,  if  you  take 
this  high  standard  for  every  thing  in  our  art,  the  bounds  of  medical 
science  will  become  very  limited.  In  the  same  way,  3'ou  could  say 
a  cataract  is  not  curable  \  for  the  cloudy  lens  is  not  again  made  clear, 
but  is  removed.  Many  of  the  most  brilliant  cures  made  by  derma- 
tologists, where  they  have  used  causticF,  must  be  regarded  as  proofs 
of  the  impotence  of  our  art ;  and  the  same  is  true  of  a  case  where 
you  prevent  a  man  from  suffocating  b\'  removing  a  tumor  from  the 
larynx.  In  the  strict  sense  of  the  word,  the  most  brilliant  "  cures  " 
are  made  in  such  diseases  as  syphilis  ;  by  antisyphilitic  internal 
treatment,  we  often  cause  extensive  and  old  morbid  products  to  dis- 
appear in  a  few  w- eeks,  as  if  by  magic.  But  such  undoubted  cures 
are  rare  in  other  diseases ;  we  often  have  to  content  ourselves  with 
destroying  the   diseased  part,  and  thus  preventing  not  only  the 


I 


RESISTANCE   TO   AMPUTATION.  803 

spread  of  the  disease  to  neighboring  parts,  but  also  its  injurious 
effects  on  the  general  system.  The  smaller  and  more  unimportant 
for  the  life  of  the  organism  the  diseased  part  is,  the  quicker  we  shall 
decide  upon  sacriticino-  it.  The  larger  the  part  to  be  removed,  the 
greater  not  only  the  danger  attending  the  removal,  but  the  mere 
effect  will  it  have  on  the  subsequent  usefulness  of  tlie  patient.  This 
brings  an  unscientific  social  element  among  indications  for  amputa- 
tion, which  is  frequently  very  important.  Thus,  a  rich  man  could 
live,  and  to  a  certain  extent  enjoy  life,  even  after  losing  all  four  ex- 
tremities ;  for  the  physiological  uses  of  the  limbs  may  be  supplied 
by  the  labor  of  other  persons,  and  labor  may  be  bought.  But  for 
any  one  dependent  on  the  work  of  his  hands  or  feet,  the  loss  of  a 
limb,  or  in  some  artisans  the  maiming  of  a  finger,  may  ruin  his  pros- 
pects in  life.  How  can  a  postman,  bricklayer,  or  turner  get  on 
without  sound  legs,  or  a  jeweler  or  shoemaker  with  only  one  hand  ? 
I  have  often  had  to  remove  a  finger  which  had  been  drawn  into  the 
hollow  of  the  hand  by  a  cicatrix,  because  it  prevented  the  patient 
from  grasping  an  axe  or  spade  as  his  business  required  him  to  do. 
How  often  I  have  heard  patients  say  :  "So  you  can't  cure  my  foot? 
1  would  sooner  die  than  lose  it  ;  for  what  could  I  do  without  it?  I 
am  a  ruined  man  ;  I  cannot  stand  it  ;  you  shall  never  take  it  off !" 

But  one  does  not  readily  die  from  chronic  diseases  of  the  extrem- 
ities ;  the  pain,  continued  for  weeks,  months,  or  years,  finally  wears 
out  the  strongest;  and  then  love  of  life,  and  becoming  accustomed 
to  the  thought  of  being  able  to  earn  a  livelihood  even  after  losing  a 
limb,  finally  decides  most  patients  to  submit  to  amputation,  though 
sometimes  not  till  it  is  too  late. 

Tfje  opposition  of  severely  wounded  persons  to  amputation  varies 
greatly  ;  it  depends  chiefly  on  the  appearance  of  the  injured  part, 
and  on  the  amount  of  pain.  If  the  extremity  be  torn  to  shreds,  and 
pieces  of  crushed  bone  be  seen  in  it,  there  will  be  little  opposition  to 
amputation  ;  the  same  is  true  when  there  are  excessive  pain  and  great 
ecchymosis,  and  the  fingers  and  toes  are  immovable.  But  if  this  be 
not  the  case;  if  the  severity  of  the  injury  be  only  recognized  by  the 
surgeon— for  instance,  if  it  be  a  wound  of  a  joint  with  fracture  of  a 
bone,  without  much  deformity  or  functional  disturbance,  if  the  pa- 
tient can  move  his  toes  and  fingers  and  has  no  pain— it  is  often  dif- 
ficult to  explain  to  him  the  necessity  for  an  operation  ;  it  requires 
confidence  in  the  surgeon  as  in  a  superhuman  being  to  induce  him  to 
permit  amputation.  You  will  often  find  your  surgical  notions  met 
by  insuperable  objections.  If,  after  a  few  days,  the  dangerous 
changes  which  you  may  have  foretold  occur,  and  the  patient  begs  to 
be  amputated,  you  may  sometimes  have  to  say,  "  It  is  too  lute  ; "  but 


804  AMPUTATIONS,   EXARTICULATIOXS,   AND    RESECTIONS. 

will  you  be  so  cruel  as  to  say,  "  I  told  you  so  "  ?  It  is  a  trying  rao- 
ment  for  the  surgeon.  If  there  is  the  slightest  prospect  of  a  cure, 
even  under  such  circumstances,  he  will  amputate  ;  the  hope  of  saving 
under  such  circumstances  a  patient  who  has  been  "given  up  "  is  an 
evidence  of  youthful  and  justifiable  pride  in  surgical  power.  But 
when  we  fail  to  succeed  time  after  time,  and  grow  weary  of  trying 
for  the  rare  successes,  we  become  more  resigned,  and  watch  with  re- 
gret the  sinlcing  ship  without  sending  out  the  life-boat  of  our  surgi- 
cal skill.  Seductive  as  may  be  the  hope  of  accomplishing  wonders 
by  unusual  skill,  we  must  still  shun  the  danger  of  showing  our  skill 
to  be  impotent.  For  too  many  mishaps  finally  annul  in  every  con- 
scientious surgeon  the  pleasure  and  trust  in  his  art. 

I  hope  what  has  been  said  will  make  you  think  seriously,  before 
any  important  operation,  whether  3'ou  should  operate,  and  how.  You 
must  remember  that  in  any  serious  operation  you  require  the  patient 
to  put  his  life  in  your  hands,  and  you  owe  him  your  best  knowledge 
and  skill. 

It  is  difficult  to  give  general  indications  for  amputations  and  re- 
sections ;  almost  any  general  rule  in  surgery  might  be  criticised  in 
special  cases ;  but  it  will  be  well  to  epitomize  what  1  have  said  on 
these  points  daring  the  present  lectures,  and  I  will  add  something 
about  the  p2rformanc3  of  the  operations  and  the  after-treatment  of 
the  patient. 

AMPUTATIONS   AND   EXAPvTICULATIONS. 

In  some  injuries  of  the  extremities,  it  is  certain  from  the  first 
that  the  limb  must  become  gangrenous,  or  that  the  consequent  sup- 
puration  will  be  so  great  as  to  seriously  endanger  the  life  of  the 
patient.  But  if  primary  amputation  is  not  submitted  to,  and  gan- 
grene is  far  advanced,  amputation  will  probably  not  prevent  death  ; 
and  the  same  is  true  in  advanced  phlegmonous  inflammation  with 
septicaemia.  The  only  hope  of  success  is  in  cases  where  you  can  am- 
putate in  perfectly  healthy  tissue ;  for  instance,  when,  in  traumatic 
gangrene  Avhich  has  spread  from  an  injury  of  the  hand  or  forearm 
to  the  elbow-joint,  you  can  amputate  high  in  the  arm  or  at  the 
shoulder-joint.  Under  analogous  conditions,  similar  operations  on 
the  thigh  or  hip-joint  are  much  less  favorable. 

If  conservative  treatment  has  been  successfull}^  tried  for  a  time, 
and  then  symptoms  of  pyremia  appear,  amputation  ma}^  be  resorted 
to  with  some  hope  of  success  in  the  upper  extremities,  but  rarely  so 
in  the  lower  limbs. 

In  these  so-called  secondary  amputations,  a  favorable  result  is 
more  probable  when  pjgemic  symptoms  have  not  appeared,  but  from 


I 


OCCASIONS   FOR  AMPUTATION.  8O5 

excessive  inflammation  the  skin  has  suppurated  so  extensively  that 
we  cannot  hope  for  the  wound  to  close ;  or  when  the  patient  has 
fallen  into  a  marasmic  state  from  slow  suppuration  of  large  joints  or 
bones. 

Injuries  of  the  hands  or  feet  may  also  lead  to  amputation,  when 
of  such  a  nature  that,  under  the  most  favorable  condition,  they  would 
induce  a  useless,  constantly  ulcerating  stump.  After  evulsions  or 
crushed  wounds  especially,  the  bones  may  protrude  and  the  stump 
may  require  a  regular  amputation.  The  results  of  frost-bite  must  be 
treated  in  the  same  way ;  but  in  the  lower  limbs  we  should  not 
delay  amputating  too  long  when  the  line  of  demarkation  has  been 
formed  ;  sloughing  off  of  considerable  portions  of  the  body  too  often 
induces  septicaemia,  which  may  be  prevented  by  early  amputation  in 
cases  of  gangrene  from  frost-bite  or  burns. 

In  acute  idiopathic  inflammations  of  bones  and  joints,  by  early 
diagnosis  and  treatment,  we  are  constantly  learning  to  preserve 
limbs  by  making  proper  openings  for  the  pus,  and  fixing  the  limbs  in 
good  position.  Still,  cases  do  occur  where  the  patient  can  only  be 
saved  by  well-timed  amputation  ;  but  the  choice  of  the  proper  time 
is  difficult,  as  it  is  a  question  whether  and  how  long  the  patient  can 
bear  the  suppuration  and  fever. 

In  regard  to  so-called  spontaneous  gangrene,  or,  as  old  surgeons 
called  it,  grangrene  from  internal  causes,  we  must  carefully  consider 
each  case.  If  the  gangrene  be  due  to  arterial  embolism,  and  there 
be  general  disease,  the  limb  should  be  amputated  as  soon  as  demar- 
kation occurs.  In  gangrene  after  typhus  and  severe  exanthemata, 
we  may  wait  till  the  patient  has  somewhat  recovered.  In  true  senile 
gangrene  we  rarely  amputate.  If  the  gangrene  be  limited  to  one 
or  a  few  toes,  they  may  be  left  to  come  off  spontaneously.  If  it 
extend  to  the  tarsus,  it  is  rarely  limited  to  that  part  ;  but  should  it 
be,  we  loosen  the  protruding  bones,  and  strive,  with  the  least  i^ossi- 
ble  injury  of  the  soft  parts,  to  secure  enough  substance  to  cover  the 
stump. 

The  cliief  chronic  diseases  which  give  occasion  for  amputation 
are  the  chronic  inflammations  of  bones  and  joints.  Caries  of  many 
bones  of  the  carpus  or  tarsus,  of  the  knee-joint  in  non-tuberculous 
adults,  of  the  hip,  shoulder,  or  elbow  joints,  rather  demand  resection 
if  any  operation  is  required  ;  amputation  is  a  secondary  question. 

Extensive  incurable  ulcers  and  incurable  or  frequently  recurring 
pachydermy  of  the  leg  often  demand  amputation,  unless  the  patient 
is  to  be  condemned  to  constant  pain  and  to  be  permanently  bed- 
ridden. 

Large  aneurisms  of  the  femoral  artery,  especially  if  likely  to  rupt- 


806  AMPUTATIONS,   EXARTICULATIONS,    AND   RESECTIONS. 

ure,  if  they  cannot  be  cu-'od,  would  certainly  prove  fatal  if  amjDuta- 
tion  were  not  performed. 

In  tumors  of  the  extremities  which  are  firmly  adherent  to  femur, 
humerus,  or  tibia,  and  grow  in  between  the  soft  parts,  we  must  am- 
putate. Tumors  merely  attached  to  the  ulna,  radius,  or  fibula,  and 
not  extending-  inio  the  soft  parts,  may  be  successfully  removed  by 
partial  resection,  or  even  b}'  removal  of  the  bone. 

Lastly,  amputation  may  be  desirable  on  account  of  distortion  or 
malformation  of  the  foot  preventing  a  patient  from  walking. 

Now,  regarding  the  method,  we  may  operate  through  the  joint, 
or  saw  through  the  bones.  Both  ways  have  their  advantages  and 
objections.  Amputation  through  the  joint  appears  to  be  the  most 
natural  and  simple,  and  least  injurious.  The  soft  parts  may  even 
unite  to  the  cartilage  by  first  intention,  or  the  cartilage  may  suppu- 
rate and  be  thrown  off,  in  which  case  the  healing  is  by  granulations 
growing  from  the  bone.  The  medullary  cavity  of  the  bone  is  not 
opened,  so  we  escope  the  possibility  of  primary  infection  of  the  me- 
dulla at  the  time  of  or  shortly  after  the  operation. 

The  objections  to  this  operation  are,  that  portions  of  the  serous 
synovial  sac  remain  and  have  little  tendency  to  primary  adhesions, 
and  pus  readily  collects  in  them  after  the  wound  has  united.  More- 
over, the  soft  parts  required  to  cover  the  large  articular  surfaces  are 
very  extensive,  so  that  the  wounded  surface  must  be  very  large.  In 
case  of  the  knee  or  elbow  joint,  the  length  of  the  flap  required  is 
such  that  we  might  perhaps  make  a  high  amputation  of  the  leg  or 
forearm.  The  stumps  left  after  exarticulation  are  unfavorable  for 
the  application  of  artificial  limbs ;  for  instance,  after  exarticulation 
at  the  knee,  the  joint  of  the  artificial  leg  would  have  to  be  lower 
than  the  knee  on  the  sound  side. 

In  amputations  we  have  the  advantage  of  being  able  to  choose 
where  we  will  remove  the  limb,  although,  from  certain  empirical 
reasons,  and  for  greater  convenience  in  applying  artificial  limbs, 
certain  places  are  preferred.  We  generally  require  less  flap  to  cover 
the  stump  from  an  amputation  than  from  an  exarticulation.  Sawing 
the  bone  is  not  a  very  formidable  complication  of  this  operation, 
although  in  many  cases  more  or  less  extensive  necrosis  of  the  sawed 
surface  results.  If  the  medulla  in  its  cavity  or  in  the  spongy  sub- 
stance be  infected  by  a  dirty  sponge  during  the  operation,  or  if  the 
soft  parts  become  so  adherent  that  pus  forming  in  the  medulla  can- 
not escape,  severe  acute  osteomyelitis  results,  which  may  induce 
septictemia  and  death.  In  more  favorable  cases  the  osteomyelitis  is 
limited,  and  we  have  necrosis  of  the  bone  in  the  stump  ;  after  six  or 
eight  weeks  the  necrosed  portion  may  be  removed  as  a  sequestrum  ; 


METHOD   OF  AMPUTATION.  ^q^ 

a  bony  envelope  has  formed  around  it,  which  replaces  the  lost  bone. 
When  speaking  of  complicated  fractures,  we  have  already  stated  that 
•  osteophytes  may  form  at  the  amputated  end  of  the  bone.  Osteo- 
myelitis of  the  stump  is  difficult  to  recognize  at  its  onset  ;  but  you 
may  assume  its  presence  if  on  the  third  or  fourth  day  after  the 
operation  the  patient,  who  has  previously  been  free  from  fever,  sud- 
denly has  a  high  fever  with  chills  and  diarrhoea,  while  the  stump 
shows  no  signs  of  inflammation,  or  perhaps  most  of  it  has  healed 
by  first  intention.  Hence,  as  the  cause  of  the  fever  is  not  inflamma- 
tion of  the  soft  parts,  it  must  be  in  the  bone,  unless  there  be  some  ex- 
ceptional complication.  At  all  events,  in  such  cases  you  should  open 
the  stump  and  expose  the  bone,  to  evacuate  any  pus  that  may  have 
formed.  Occasionally  you  may  in  this  way  save  the  patient,  but 
usually  it  is  too  late ;  for,  from  the  uncertainty  of  the  symptoms,  we 
rarely  have  the  courage  to  lay  open  the  beautifully-healed  wound, 
although  it  would  do  no  great  harm  even  if  we  were  mistaken  in  the 
diagnosis. 

In  amputations  and  exarticulations  the  chief  points  are: 

1.  To  do  the  operation  with  as  little  loss  of  blood  as  possible. 

2.  To  arrest  the  bleeding  completely,  so  that  there  may  be  no 
secondary  haemorrhage. 

3.  To  cover  the  end  of  the  bone  with  soft  parts,  so  that  tlicy 
may  unite  easily  and  completelj'. 

Jn  regard  to  the  first  two  points,  I  have  nothing  to  add  to  what 
I  have  already  said.  Before  the  operation  J^smco'cli's  bandage 
should  be  applied;  the  amputation  may  then  be  done  without  losing 
a  drop  of  blood.  After,  the  operation  I  twist  the  small  arteries, 
and  close  the  larger  ones  by  acupressure  or  catgut  ligature.  After 
exarticulation  of  the  femur  or  humerus  I  ligate  the  femoral  and 
axillary  arteries,  because  I  have  found  it  such  slow  work  to  apply 
the  needles  securely. 

The  end  of  the  bone  must  be  covered  with  soft  parts,  which  must 
heal  over  it ;  if  this  does  not  occur,  and  the  bone  projects,  the  granu- 
lations growing  out  of  it  either  fail  to  cicatrize  and  form  an  ulcer,  or, 
if  they  do  cicatrize,  the  cicatrix  adherent  to  the  bone  has  so  little 
vitality  that  wearing  an  artifical  limb  soon  makes  it  sore.  This  is 
very  unfortunate,  as  it  prevents  the  patient  from  using  the  stump, 
and  condemns  him  to  two  crutches  and  pain  in  the  ulcerated  stump 
for  the  rest  of  his  days.  Hence  the  bone  must  be  sawed  higher  up 
than  where  the  soft  parts  have  been  divided.  In  exarticulations  the 
soft  parts  must  always  be  divided  below  the  end  of  the  bone.  In 
accordance  wnth  these  principles,  the  soft  parts  may  be  divided  as 
follows,  and  properly  shaped  to  cover  the  stump  : 


808         AMPUTATIONS,  EXARTICULATIOXS,   AXD  RESECTIONS. 

1,  In  the  circular  operation  we  make  a  circular  incision  around 
the  limb,  strongly  retract  the  divided  soft  parts,  and  saw  through 
the  bone ;  then,  letting  go  the  soft  parts,  they  fall  over  the  end  of 
the  bone.  To  obtain  this  end  most  certainly  it  is  well  to  proceed  as 
follows  :  First  divide  the  skin  entirely  around  the  limb,  then  dissect 
it  up,  leaving  as  much  as  possible  of  the  cellular  tissue  with  it,  and 
leaving  the  muscular  fasciae  on  the  muscles.  When  the  skin  has 
been  dissected  up  from  two  to  four  centimetres,  turn  it  back  like  a 
cuff,  and  let  an  assistant  strongly  retract  it  with  the  other  soft  parts ; 
then  cut  through  the  muscles  down  to  the  bone  with  a  circular 
sweep  of  the  knife,  at  the  line  where  the  skin  is  turned  back  ;  the 
assistant  then  retracts  all  the  divided  parts  as  far  as  possible  ;  then 
with  a  third  circular  incision  the  deep  layer  of  muscles  is  divided 
about  two  centimetres  higher  than  the  second  cut  divided  them,  the 
periosteum  is  divided,  and  the  bone  sawed  through.  If  now  the 
parts  be  allowed  to  fall  into  place,  three  cut  surfaces  will  appear — 
througli  the  skin,  through  ttie  muscles,  and  through  the  bone,  the 
last  at  the  bottom  of  a  funnel-shaped  wound.  Where  the  limbs  are 
thin,  the  soft  parts  should  reach  about  six  centimetres  below  the  end 
of  the  bone  ;  where  thrv  are  muscular,  this  distance  should  be  two 
or  three  centimetres  more.  In  amputating  the  forearm  or  leg,  the 
last  incision  must  divide  the  interosseous  muscles  before  the  bone  is 
sawed. 

It  will  be  best  for  you  to  make  the  circular  operation  as  I  have 
just  described  it,  and  accustom  yourself  to  make  smooth  incisions, 
and  to  cut  by  drawing  the  knife,  not  by  pressing  on  it.  At  the 
same  time,  I  do  not  mean  to  say  that  the  circular  operation  may  not 
be  well  done  in  other  ways.  Sometimes  the  following  modifications 
are  advisable  ;  they  differ  partly  in  the  shaping  of  the  stump,  part- 
ly in  the  mode  of  operating : 

We  may  amputate  a  limb  in  one  plane  as  if  done  with  an  axe  or 
guillotine;  this  may  be  successfully  done  on  the  fingers.  In  the 
fingers  we  prefer  exarticulation  to  amputation  ;  but  sometimes 
fingers  are  thus  cut  off  by  machines,  such  as  circular  saws,  straw- 
cutters,  etc.,  and  the  question  arises  whether  the  stump  will  do  well 
without  surgical  interference  :  it  will  do  so,  but  this  is  merely  on 
account  of  the  anatomical  peculiarities  of  the  fingers,  where  the  skin 
is  adherent  to  the  sheaths  of  the  tendons  and  to  the  bone,  and  does 
not  retract,  while  the  tendons  retract  in  the  sheath.  The  cicatricial 
contraction  is  concentric,  and  draws  the  skin  together  to  the  centre 
of  the  divided  bone,  as  we  might  draw  a  tobacco-pouch.  At  most 
other  places  in  the  limbs  the  skin  is  so  movable  on  the  fascire,  and 
the  muscles  on  the  bone,  that  after  an  amputation  in  one  plane  the 


METHOD   OF  AMPUTATION.  809 

muscles  would  retract  from  the  bone,  and  even  the  skin  would  re- 
tract. After  the  stump,  where  the  bone  projects  like  the  point  of  a 
cone,  granulates,  the  force  of  cicatricial  contraction  will  draw  the 
skin  and  muscles  forward  if  the  latter  have  not  become  so  united 
with  the  bone  or  skin  as  to  become  iumiovable.  As  this  circular 
amputation  in  one  plane  always  leaves  conical  stumps,  it  is  only 
done  in  the  fingers  or  toes. 

Amjnitatioyi  in  two  planes  is  also  of  limited  use.  Here  the  skin 
is  divided  and  turned  back,  then  the  muscles  and  bone  are  divided 
in  the  same  plane;  this  leaves  the  stump  covered  by  the  skin  onlv. 
Where  the  bone  is  covered  by  many  muscles,  they  will  retract  great- 
ly, carrying  the  skin  back  with  them,  so  that  the  end  of  the  bone 
will  lie  in  about  the  same  plane  with  the  skin-flap ;  then,  in  heaUng, 
the  skin  becomes  attached  to  the  cone-like  section  of  the  muscles, 
and  we  have  another  conical  stump.  This  method  is  only  admissi- 
ble at  points  where  the  muscles  will  not  naturally  retract  from  the 
bones,  or  where  they  and  their  fascise  have  become  adherent  to  the 
bones  and  to  each  other  from  long-continued  precedent  disease.  It 
may  answer  in  amputations  of  the  leg  just  above  the  malleoli  or  just 
below  the  head  of  the  fibula,  or  at  analogous  points  of  the  forearm ; 
but  the  skin-flap  must  be  made  long  enough  to  cover  the  stump 
readily. 

The  circular  amputation  in  three  planes  first  described,  where 
skin,  muscles,  and  bone  are  separately  divided,  may  be  done  in  vari- 
ous ways.  For  your  first  attempts  on  the  cadaver,  I  advise  your 
doing  it  as  above  described.  Instead  of  the  last  incision  through 
the  deep  layer  of  muscles,  you  may  turn  back  the  periosteum  two 
centimetres  from  the  level  of  the  first  incision  through  the  muscles, 
and  then  saw  the  bone ;  the  effect  on  the  form  of  the  stump  remains 
the  same,  whether  the  deep  part  of  the  funnel  is  covered  by  perios- 
teum or  muscles.  This  method  may  be  done  some  w  lint  quicker  and 
more  elegantly  if,  instead  of  the  three  incisions  in  difterent  planes, 
you  divide  the  skin,  and  then  have  the  assistant  strongly  retract  the 
parts,  while  you  divide  the  muscles  by  thin  layers.  With  some 
practice  you  will  learn  to  make  the  funnel  just  the  depth  you  desire. 
But  if  your  assistant  retracts  the  soft  parts  too  energetically,  and 
you  divide  only  thin  layers,  by  the  time  you  get  down  to  the  bone 
you  will  have  gone  too  high,  and  will  have  too  much  flap.  If  the 
assistant  retracts  too  feebly,  or  if  the  soft  parts  are  adherent  to  the 
bone  and  do  not  move  freely,  while  you  cut  rapidly  and  deep,  you 
get  too  little  covering  and  have  a  conical  stump. 

Lastly,  the  funnel  has  been  made  by  cutting  obliquely  from  with- 
out inward  to  the  bone.  But  these  methods  are  not  practical,  and  I 
will  give  no  further  details. 


810  AJIPUTATIOXS,   EX  ARTICULATIONS,   AND   RESECTIONS. 

The  circular  cut  is  the  normal  method  for  all  amputations ;  it  is 
applicable  to  any  part  of  a  limb,  although  for  exarticulations  flaps 
or  oval  sections  are  more  practical. 

2.  Fla2y  Operations. — From  the  soft  parts  we  make  one  or  two 
flaps  with  which  to  cover  the  sawed  bone.  If  we  make  one  flap, 
with  a  base  half  the  circumference  of  the  limb  at  the  point  of  am- 
putation, on  the  other  side  we  usually  make  a  circular  cut  in  one  or 
two  planes.  In  flap-amputations,  also,  it  is  desirable  before  sawing 
the  bone  to  turn  back  the  periosteum  about  one  centimetre,  and  to 
saw  the  bone  about  two  centimetres  above  the  base  of  the  flap,  so 
that  as  the  muscles  retract  the  end  of  the  bone  shall  not  press  too 
much  against  the  inner  side  of  the  flap. 

I  prefer  making  the  flap  so  that  while  the  patient  lies  in  bed  it 
shall  hang  over  the  wound  without  being  held  by  sutures.  The 
lower  part  of  the  flap  should  be  of  skin,  the  upper  of  skin  and 
muscles.  The  best  way  of  doing  this  is  first  to  form  the  flap  by  an 
incision  through  the  skin,  then  retract  the  skin  and  cut  down 
through  the  muscles  to  the  bone,  then  by  two  incisions  make  a  cir- 
cular cut  on  the  posterior  part  of  the  leg.  The  length  of  the  flap 
should  be  about  one-third  the  circumference  of  the  limb  at  the  point 
of  amputation,  and  its  breadth  about  one-half  the  circumference,  or 
rather  more. 

The  single  flap  has  the  advantage  that  where  the  cause  for  am- 
putation, the  injury  or  ulcer,  or  the  line  of  demarkation  in  gangrene, 
is  irregular  in  outline,  we  may  amputate  lower  than  when  vve  per- 
form a  circular  operation,  so  that  the  stump  may  be  longer  and  the 
prognosis  better. 

I  do  not  think  the  operation  with  two  flaps  has  any  advantage 
over  the  circular  method.  We  may  make  two  lateral  flaps,  or  an 
anterior  and  posterior  one,  provided  the  amount  and  form  of  the 
soft  parts  is  analogous  to  the  circular  amputation.  Occasionally  in- 
filtration of  the  skin  prevents  its  being  retracted  well  or  turned 
back  ;  then  we  may  incise  it  in  the  direction  of  the  long  axis.  This 
would  make  of  the  circular  an  operation  with  skin-flaps,  having  the 
funnel  shape  within. 

Flaps  for  covering  the  stump  with  skin  alone  are  not  good,  for 
long  flaps  of  this  kind  readily  become  gangrenous  at  the  edge,  and, 
there  being  no  muscular  layer  between  the  skin  and  the  sawed  end 
of  the  bone,  the  latter  readily  causes  ulceration  and  perforation  of 
the  flap.  It  is  true,  this  is  no  great  misfortune,  as  the  exposed  por- 
tion of  bone  either  necroses  and  separates,  or  soon  granulates  and 
cicatrizes  ;  but  in  either  case  the  cicatrix  becomes  adherent  to  the 
bone,  and  the  subsequent  use  of  the  stump  may  give  rise  to  tedious 
ulceration. 


METHOD   OF   AMPUTATION.  811 

The  method  of  fcrming  the  flaps  by  transfixing  the  Umb  with  a 
long,  pointed  knife,  and  tlien  cutting,  usually  results  with  beginners 
in  making  a  muscular  flap,  which  is  occasionally  tongue-like,  is  cov- 
ered with  too  little  skin,  and  does  not  well  cover  the  wound.  If 
before  entering  the  knife  we  have  the  skin  strongly  retracted,  and 
pass  the  knife  flat  alongside  the  bone,  we  may  make  good  flaps  ;  but 
it  requires  more  experience  and  practice  than  the  former  methods. 

Flap  operations  are  possible  at  any  part  of  a  limb,  but  are  not 
everywhere  advisable.  By  drainage-tubes  we  may  lead  o£F  the  secre- 
tions, even  in  flaps  formed  from  below.  If  the  flaps  do  not  unite  by 
first  intention,  the  after-treatment  is  always  tedious;  for  we  have  to 
guard  against  cicatricial  contraction  rolling  them  in. 

3.  Finally,  in  a  thiid  method,  the  wound  made  is  between  a  circle 
and  a  flap  ;  it  is  called  the  oval  amputation.  The  plane  of  incision 
of  the  oval  lies  obliquely  from  above  down  ;  the  upper  part  of  the 
oval  is  more  pointed,  the  lower  more  rounded.  After  making  the  in- 
cision through  the  skin,  it  is  to  be  drawn  back,  and  the  soft  parts 
and  bone  are  to  be  divided,  as  in  the  circular  operation.  For  am- 
putations the  oval  incision  is  rarely  used,  as  it  lias  no  advantage  over 
the  circular  or  flap  operations.  In  exarticulations  of  the  fingers  and 
toes  at  the  metacarpo-  and  m^tatarso-phalangeal  articulations,  or  of 
the  big  toe  or  thumb,  the  oval  incision  is  very  useful.  In  exarticula- 
tions at  the  shoulder  or  hip  joint,  I  would  only  employ  this  method 
when  there  was  not  skin  enough  to  form  a  flap. 


I  have  still  something  to  add  in  regard  to  preparations,  assistants, 
choice  of  instruments,  and  after-treatment  of  amputations. 

While  the  patient  is  being  ana?sthetized,  or  previously  (for  it  is 
hard  to  bring  some  patients  under  anaesthesia  when  their  attention 
is  excited  by  manipulation  of  the  alFected  part),  we  carefully  cleanse 
the  part  with  soap  and  water,  especially  at  the  point  of  operation. 
Then  the  bandage  for  preventing  haemorrhage  is  applipd,  and  taken 
ofl"  again  except  the  upper  band.  Now  one  assistant  holds  the  up- 
per part  of  the  limb,  another  the  lower.  In  amputations  the  operator 
stands  so  that  he  may  assist  in  retracting  the  soft  parts,  and  that  the 
part  to  be  amputated  falls  to  his  right ;  in  exarticulations  he  should 
stand  so  that  he  can  himself,  with  his  left  hand,  control  the  move- 
ments of  the  limb  to  be  removed. 

For  amputations  and  exarticulations  of  the  toes,  we  use  small 
knives  with  blades  four  or  five  centimetres  long;  they  should  not  be 
too  much  curved  in  front,  or  the  point  will  not  enter  the  joint  readily. 
For  exarticulations  of  the  hand  and  foot,  as  well  as  for  amputations 


812  AMPCTTATIOXS,    EXARTICULATIOXS,   AND   RESECTIONS. 

of  the  lower  half  of  the  forearm  and  leg,  we  choose  a  knife  with  a 
blade  about  15  centimetres  long ;  for  the  upper  part  of  the  forearm, 
the  arm,  upper  part  of  the  leg,  and  the  lower  part  of  the  thigh,  the 
blade  should  be  from  15  to  25  centimetres  long  ;  for  high  amputa- 
tions and  exarticulations  of  the  thigh,  it  should  be  25  to  35  centi- 
metres long.  If  you  have  two  small  knives  with  blades  5  centi- 
metres, and  one  each  of  15,  25,  and  35  centimetres,  it  will  be  enough. 
In  amputating  I  do  not  like  changing  knives,  and  so  prefer  having 
the  cutting  edge  somewhat  rounded  in  front,  so  that  the  skin  may 
be  dissected  up  with  the  point  of  the  same  knife.  Other  operators 
prefer  doing  this  with  a  scalpel,  then  taking  another  knife  to  divide 
the  muscles,  and  still  another  for  the  periosteum.  For  pushing  back 
the  periosteum,  I  use  a  raspatorium,  though  sometimes  this  may  be 
done  by  the  nail  alone.  A  skilled  assistant  will  with  his  hands  re- 
tract the  soft  parts  sufficiently  to  give  the  operater  room  to  cut  and 
saw ;  but  pieces  of  clean  linen  may  be  used  for  this  purpose.  Some 
operators  take  pride  in  amputating  even  tliick  limbs  with  small 
knives,  thus  pushing  the  simplicity  of  instruments  to  the  utmost 
point.  These  points,  while  not  unessential,  depend  greatly  on  habit 
and  tradition,  and  each  one  may  follow  his  own  taste. 

Saws  for  amputation  are  usually  bow-shaped.  The  bow  should 
not  be  too  high,  or  it  will  make  the  saw  unsteady ;  the  handle  should 
be  broad  and  lie  securely  in  the  hand.  The  blade  should  not  be 
more  th:in  two  centimetres  broad,  and  the  teeth  should  be  bent  out- 
ward, else  the  saw  will  catch ;  and  it  will  be  still  more  apt  to  do  so 
if  the  assistant  holding  the  lower  part  of  the  limb  raise  it  instead  of 
depressing  it  somewhat.  After  sawing  the  bone,  I  usually  cut  oflF 
the  sharp  edges  with  bone-nippers. 

When  the  amputation  is  completed,  the  vessels  are  twisted,  com- 
pressed with  needles,  or  ligated ;  the  instruments  required  for  this 
should  be  all  ready.  In  one  of  these  ways  we  first  close  all  the  ves- 
sels we  can  find,  then  relax  the  elastic  band  or  tourniquet,  doing  it 
in  such  a  way  that  the  assistant  can  renew  the  compression  if  the 
bleeding  becomes  excessive  ;  then  we  apply  acupressure  or  ligatures 
to  any  other  arteries  we  see  bleeding.  In  amputations  of  the  thigh 
or  arm  we  may  have  venous  haemorrhages,  as  the  valves  are  insuifi- 
cieut.  The  veins  may  be  ligated  or  compressed  by  needles  ;  torsion 
of  veins  is  dangerous.  Arterial  hasmorrh&ge  from  the  medullary 
cavity  of  bones  is  very  unpleasant  ;  it  is  rarely  severe.  But  either 
poking  into  the  medulla  with  forceps  or  firm  pressure  with  a  sponge 
is  dangerous  ;  and  we  should  entirely  avoid  the  application  of  styp- 
tics, especially  liq.  ferri.  I  advise  letting  the  bleeding  alone  till  all 
other  vessels  are  cared  for ;  if  by  that  time  it  has  not  ceased  spon- 


AFTER-TREATMENT   OF   AMPUTATIONS.  813 

taneously,  we  may  compress  the  main  artery  of  the  Hmb  for  a  while 
with  the  finger.  During  the  dressing  we  should  only  use  new,  soft 
sponges. 

We  should  wait  till  the  bleeding  is  entirely  arrested  ;  it  is  even 
desirable  to  leave  the  w^ound  exposed  to  the  air  for  a  time.  After 
circular  or  oval  amputations,  the  wound  is  generally  united  in  a  ver- 
tical direction.  I  apply  from  two  to  four  sutures  in  the  upper  part 
of  the  wound,  leaving  the  lower  part  open.  I  secure  flaps  in  the 
position  they  are  to  occupy  by  from  two  to  four  sutures,  previously 
placing  a  drainage-tube  dipped  in  glycerine  in  the  wound  across 
the  bone,  so  that  the  two  ends  project  from  the  angles  of  the 
wound. 

[In  amputations  at  the  upper  third  of  the  leg,  the  spine  of  the 
tibia  is  apt  to  press  on  the  soft  parts  ;  to  avoid  this,  the  tibia  may 
be  sawed  obliquely  downward  and  backward  :  this  is  easier  than 
cutting  it  w^ith  forceps. 

Instead  of  applying  EstnarclCs  bandage,  by  which  pus  may  be 
forced  into  the  veins,  or  blood-clots  there  be  driven  into  the  circu- 
lation, we  may  have  the  limb  held  vertically  for  ten  or  fifteen  min- 
utes, and  then  tightly  apply  an  elastic  bandage  above  the  proposed 
point  of  operation. 

If  skilled  in  finding  the  vessels,  you  may  ligate  them,  apply 
drainage-tubes,  sew  up  the  wound,  and  apply  an  exact  compression 
dressing,  while  the  limb  is  kept  elevated,  and  then  remove  the  elastic 
bandage  ;  but  do  not  try  this  with  your  first  operations,  as  it  re- 
quires practice.  It  is  better,  after  removing  the  bandage,  to  ligate 
any  small  vessels  that  have  been  overlooked,  wash  off  the  wound 
with  a  four-per-cent.  solution  of  carbolic  acid,  and  then  unite  it 
exactlj^  The  ligatures  of  disinfected  catgut  or  silk  are  cut  short, 
the  edges  of  the  skin  are  brought  together  so  that  the  line  of  union 
may  be  vertical  ;  after  from  two  to  four  drainage-tubes  have  been 
inserted  at  proper  places,  so  as  to  remove  secretion  entirely  and  by 
the  shortest  way,  these  are  cut  off  level  with  the  skin  and  fastened 
there,  first  satisfying  yourself  that  they  act  well  by  passing  a  two- 
per-cent.  solution  of  carbolic  acid  through  them.  Then  Lister's 
dressing  is  to  be  applied,  or  the  iodoform  dressing  of  which  w^e  have 
already  spoken  ;  the  parts  where  the  drainage-tubes  are  to  lie,  and 
the  end  of  the  bone,  should  have  very  little  iodoform  applied  ;  then 
the  edges  of  the  skin  are  to  be  united  and  more  iodoform  ai)plied, 
with  greased  cotton  and  gutta-percha  paper  outside. 

The  stump  should  be^kept  elevated  for  a  day,  then  laid  nearly 
horizontal.  The  dressing  is  usually  changed  in  twenty-four  hours, 
then,  if  all  goes  right,  not  for  four  or  five  days,  when  the  drainage- 


814  AMPUTATIONS,  EXARTICULATIONS,  AND   RESECTIONS. 

tubes  should- be  removed.  After  this  the  dressing  is  only  to  be 
changed  when  permeated  by  secretion,  or  from  some  accident. 

Normally  the  stump  should  be  entirely  free  from  pain,  redness, 
and  swelling,  and  there  should  be  no  febrile  reaction,  except  a 
slight  rise  the  first  and  second  day.  The  sutures  are  generally  re- 
moved at  the  third  di-essing  ;  after  a  fortnight,  even  if  the  wound 
is  not  entirely  healed,  we  may  apply  a  simple  compress  wet  with 
solution  of  acetate  of  alumina,  or  some  adhesive  strips.  The  iodo- 
form dressing  is  not  usually  changed  for  four  or  five  days,  and  the 
drainage-tubes  are  then  taken  out,  unless  absorbable  tubes  of  de- 
calcified  bone  have  been  used,  then  the  dressing  may  be  left  longer.] 

Should  the  stump  swell,  or  the  patient  become  feverish,  the  ad- 
hesions of  the  wound  should  be  broken  up  with  the  finger,  and  any 
pus  that  has  collected  be  allowed  to  escape.  If  there  are  neuralgic 
pains  or  frequent  twitchings,  subcutaneous  injections  of  morphine 
may  be  made. 

If  arterial  seeondary  hmmorrhage  occurs  within  twenty-four 
hours,  the  artery  should  be  sought  for  and  closed  ;  if  it  comes  later, 
in  the  second  or  third  week,  when  the  wound  is  granulating,  it  is 
best  first  to  seek  the  bleeding  point  and  close  it  firmly  ;  if  this  at- 
tempt is  unsuccessful,  and  the  ha?morrhage  recurs  after  })rolonged 
digital  compression,  the  main  artery  of  the  limb  should  be  ligated. 

Treating  the  stump  in  the  water-bath  was  attended  by  so  many 
difficulties  that  it  was  soon  given  up. 

When  treating  of  circular  amputations  made  in  one  plane,  we 
spoke  of  the  unfortunate  occurrence  of  conical  stianps.  They  may 
be  due  to  unsuitable  incisions  through  the  soft  parts  or  deficiency 
of  soft  parts  ;  but  these  are  not  the  only  or  even  most  frequent 
causes.  In  marasmic  jiatients  there  is  sometimes  such  an  atrophy 
of  the  soft  parts  of  the  stump  that  they  grow  thinner  and  shorter, 
and  sink  more  and  more  on  the  bone. 

If  we  see  that  a  conical  stump  is  forming,  we  may  apply  adhe- 
sive plaster  and  weights,  as  in  coxitis,  to  draw  the  skin  down,  or  at 
least  to  aid  the  concentric  contraction  of  the  granulating  surface  by 
freeing  it  from  the  opposition.  If  the  patient  bears  this  without 
pain  in  the  stump  or  fever,  it  may  be  of  benefit ;  but  if  these  symp- 
toms appear,  it  must  be  abandoned.  If,  as  a  result  of  osteomyelitis, 
extensive  necrosis  of  the  stump  occurs,  it  is  indeed  shortened,  but 
the  osteophytes  which  have  formed  prevent  too  much  shrinkage, 
and  they  do  not  atrophy  for  years.  My  experience  does  not  show 
that  the  stump  becomes  less  conical  by  the  detachment  of  the  seques- 
trum ;  usually  an  operation  is  required.  I  split  the  mass  of  granula- 
tions upward  into  the  skin  and  downward  to  the  bone,  then  push  the 


AFTER-TREATMENT   OF   AMPUTATIONS.  815 

raspatorium  along  the  bone,  separating  the  periosteum  and  osteo- 
phytes from  the  bone  so  far  into  the  soft  parts  that  they  may  cover 
the  stump  of  bone  which  shall  be  left.  In  sawing,  I  use  a  cliain-saw 
whose  ends  I  bring  out  above  while  the  loop  is  around  the  bone. 
In  limbs  with  two  bones,  this  subperiosteal  resection  or  amputation  is 
done  on  both  bones.  Care  must  be  taken  that  the  secretion  from 
the  periosteal  canal  from  which  the  bone  is  removed  has  a  free 
escape  ;  it  is  much  inclined  to  close  in  front  by  first  intention ;  then 
pus  may  collect  deeper  in,  decompose,  and  cause  osteomyelitis.  I 
had  such  an  unfortunate  case  in  the  army-hospital  at  Mannheim,  in  a 
soldier  who  was  amputated  successfully  for  a  severe  injury  of  the 
knee,  and  finally  died  in  this  way.  At  that  time  I  did  not  know  of 
this  danger  from  subperiosteal  resection  of  an  amputation-stump,  all 
the  previous  cases  that  I  had  operated  on  in  this  way  having  done 
well. 

Observation  of  old  amputation-stumps  shows  that  they  change 
considerably  in  the  course  of  years :  some  grow  very  thin ;  the  mus- 
cular covering  or  flaps  atrophy  from  disuse,  so  tliat  only  the  skin 
remains.  In  the  course  of  years  most  stumps  become  conical  even 
if  covered  with  skin  alone.  This  is  the  more  certain  to  occur,  the 
more  poorly  nourished  and  marasmic  the  patient,  and  especially  in 
those  who  have  been  amputated  for  caries  of  the  joint,  and  who  subse- 
quently have  caries  of  other  bones  or  in  the  stmnp,  or  pulmonary  tuber- 
culosis or  lardaceous  disease.  The  bones  of  such  stumps  atrophy,  and 
their  cortical  layer  becomes  thin.  Short  thigh-stumps  are  about  the 
only  exception.  If  tliese  are  used  much  in  walking,  the  muscles 
going  from  the  pelvis  to  the  thigh  develop,  the  skin  and  cellular 
tissue  participate  in  the  good  nutrition,  and  the  stumps  become 
larger  than  they  were  shortly  after  the  operation.  From  most  old 
amputation-stumps  being  covered  only  by  skin,  while  the  muscles 
have  disappeared,  some  have  asserted  that  it  is  entirely  useless  to 
employ  muscle  for  covering  the  stump  ;  but  we  have  already  shown 
that  they  would  not  heal  so  well. 

In  Lecture  IX.  we  treated  of  neuromata  in  the  amputation- 
stump. 

Regarding  the  prognosis  for  amputations,  we  can  only  say  in 
general  terms  that  they  are  the  more  dangerous  the  nearer  they  are 
to  the  trunk.  Much  depends  on  the  general  condition  of  the  patient 
at  the  time  of  operation.  Amputations  for  injuries  arc  always  less 
successful  than  those  made  for  chronic  diseases ;  but  in  each  case 
there  are  many  points  that  we  will  not  lose  our  time  about  here. 

Surgeons  pay  too  little  attention  to  the  subsequent  fate  and  the 
artificial  limbs  of  those  they  amputate.     You  will  hear  many  com- 


816  AMPUTATIONS,   EX  ARTICULATIONS,   AND   RESECTIONS. 

plaints  from  these  patients.  Pains  in  the  stump  with  each  change 
in  the  weather,  excoriations  of  the  cicatrix,  pressure  of  the  artificial 
limb  at  one  place  or  another,  and  constant  repairs  of  it,  are  the  most 
frequent  complaints.  Some  suffer  for  years  from  the  sensation  of 
still  having  their  limb  ;  for  instance,  after  amputation  of  the  thigh 
they  exclaim  :  "  I  have  a  pain  in  the  little  toe  ;  the  big  toe  is  being 
torn ;  my  foot  lies  in  a  bad  position,"  etc.  During  the  first  days 
and  weeks  after  amputation  these  sensations  are  the  rule,  and  are 
so  decided  and  strong  that  by  covering  the  stump  we  may  deceive 
patients  for  weeks  about  the  loss  of  their  limbs ;  but  I  have  seen 
patients  who  had  the  same  sensations  after  years. 

As  regards  the  substitute  for  the  limb,  mucii  depends  on  the 
patient's  position  in  life  and  his  means,  not  only  for  buying  a  limb, 
but  for  keeping  it  in  repair  and  replacing  it  when  worn  out. 

Artificial  arms  and  well-imitated  liands  are  articles  of  adornment 
and  luxury.  Active  movements  of  the  fingers  have  not  been  attained, 
but  mechanism  for  grasping  has  been  arranged  with  springs  which 
are  opened  by  the  other  hand.  I  will  not  enter  into  more  detail. 
For  the  arm  or  forearm,  a  workman  may  have  a  leather  case  held  in 
place  by  straps,  and  having  a  solid  piece  of  wood  at  its  lower  end, 
into  which  ma}'^  be  fastened  hooks,  etc.  On  Sunda}'  he  may  put  on 
a,  hand  carved  from  wood.  It  is  astonishing  what  intelligent  persons 
can  accomplish  with  such  apparatuses.  I  have  a  long,  beautifully- 
written  letter  from  a  man  for  whom  I  amputated  both  hands.  He 
was  an  engineer,  and  got  his  hands  caught  and  crushed  in  a  rapidly- 
revolving  water-wheel.  Subsequently,  without  hands,  he  earned  his 
living  by  writing. 

As  regards  the  lower  limbs,  there  are  few  stumps  on  which  the 
patient  can  bear  the  entire  weight  of  tlie  body ;  and  these  are  the 
stumps  after  amputations  and  exarticulations  of  the  foot,  and  some- 
times after  exarticulations  at  the  knee.  In  all  other  cases  the  pa- 
tients rest  on  the  condyles  of  the  tibia  or  tuber  ischii,  which  bony 
parts  are  supported  on  a  firm,  cushioned  ring,  which  forms  the  upper 
end  of  the  shield  of  the  artificial  limb,  and  into  which  the  stump  is 
introduced.  After  amputations  of  the  leg,  it  is  desirable  to  divide 
the  weight  of  the  body  on  these  two  points.  Another  way  is  for  a 
patient  whose  leg  lias  been  amputated  to  rest  the  bent  knee  on  a 
wooden  leg;  this,  of  course,  prevents  any  motion  at  the  knee-joint. 
In  regard  to  the  construction  of  artificial  limbs  and  wooden  legs,  I 
will  say  nothing,  except  to  add  that  for  their  use  a  certain  amount 
of  skill  and  intelligence  is  required,  as  well  as  pecuniary  means  for 
attending  to  the  repairs  so  often  required  by  any  artificial  limb. 
Hence,  for  working-people,  as  most  of  our  hospital  patients  are,  it 


PROGRESS  OF  AMPUTATIONS.  817 

is  better  to  have  firm  wooden  legs.  Even  many  from  the  higher 
classes,  who  have  been  amputated,  and  have  worried  over  artificial 
limbs  for  years,  finally  resort  to  wooden  legs.  Walking  with  an  ar- 
tificial leg  and  a  wooden  one  differs  so  much,  that  one  who  has  been 
accustomed  to  the  latter  for  years  can  only  use  the  former  after  very 
patient  trial. 

Simple  as  the  operations  for  amputation  and  exarticulation  now 
seem,  we  must  remember  that  from  Hippocrates  to  the  present  time 
progress  has  constantly  been  made  in  them.  That  large  portions  of 
limbs  could  be  lost  without  danger  to  life  was  first  taught  by  their 
spontaneous  detachment  by  gangrene  ;  the  first  amputations  were 
made  for  the  purpose  of  removing  such  gangrenous  limbs,  and  the 
bone  was  sawed  at  the  line  of  demarkation.  The  indications  for 
amputation  grew  very  slowly.  What  especially  retarded  the  intro- 
duction of  this  operation  was  not  knowing  how  to  check  the  hicmor- 
rhage  with  certainty  ;  styptics  and  the  hot  iron  answered  for  the 
leg  and  forearm,  but  not  elsewhere.  Hence  the  progress  of  ampu- 
tations depended  on  that  of  the  methods  for  arresting  ha?morrhao-e. 
The  greater  amputations  were  only  ventured  on  after  the  introduc- 
tion of  the  ligature  and  tourniquet.  The  method  of  amputating 
limbs  by  strangulating  them  with  a  ligature  was  first  introduced  by 
Guy  de  Chaidiac  and  improved  by  Ploiicquet.  Of  late  this  method 
has  been  tried  again  by  the  ecraseur  [Chassaignac),  the  galvano- 
caustic  (  V^on  Srims),  and  the  elastic  ligature  {Dittel),  but  has  met 
with  little  popularity.  Later  surgeons  particularly  directed  their 
attention  to  amputating  as  rapidly  as  possible,  so  as  to  cause  the 
least  pain,  and  to  dividing  the  soft  parts  so  as  to  avoid  conical 
stumps.  Now  that  we  have  anaesthetics,  and  can  avoid  hjemor- 
rhage  by  the  elastic  bandage,  rapidity  in  amputations  and  exarticu- 
lations  is  a  matter  of  small  moment.  Attention  is  turned  to  the 
formation  of  the  stump,  and  since  the  beginning  of  this  century  to 
attempts  to  secure  healing  by  first  intention,  and  especially  to  the 
avoidance  of  any  infection  from  without  or  from  the  secretions  of 
the  wound,  and  to  escaping  pyaemia,  the  most  dangerous  enemy  of 
amputations.  The  latter  points  now  chiefly  claim  our  attention,  and 
recent  proposed  changes  in  the  method  of  operating  all  have  them 
in  view. 

The  first  method  which  was  used  in  Celsiis's  time  was  a  circular 
incision  with  retraction  of  the  skin.  This  was  gradually  improved 
on.  Lowdham  (1679)  is  usually  regarded  as  the  originator  of  the 
single  flap,  which  method  was  perfected  by  Verduin  (1696).  liava- 
ton  and  Vermale  are  said  to  have  been  the  first  to  use  two  flaps. 
63 


618  AMPUTATIONS,   EXARTICULATIONS,  AND   RESECTIONS. 

The  oval  amputation  was  first  made  by  Scoutetten.  You  will  find 
very  accurate  accounts  of  amputations  in  SprengeVs  histories  of 
operations,  and  in  I/inharfs  excellent  work  on  operations,  which  I 
cannot  too  highly  recommend. 

RESECTIONS. 

I  will  now  make  a  few  general  remarks  on  resections.  As  previ- 
ously stated,  sawing,  chiseling,,  or  gouging  out  diseased  or  injured 
pieces  of  bone  from  the  body  of  the  bones,  is  called  "resection  in 
the  continuity."  Most  operations  of  this  nature  were  mentioned 
when  treating  of  complicated  fractures,  necrosis,  or  caries ;  as  were 
the  so-called  osteotomies  for  orthopedic  purposes.  You  will  see 
these  operations  so  often  in  the  clinic  that  I  will  not  describe  them 
here;  they  are  mostly  simple.  The  indications  for  them  appear  from 
what  has  been  said. 

We  have  also  spoken  of  "  resections  of  joints."  I  have  alread\' 
told  you  that  these  operations,  which  in  civil  practice  occur  espe- 
cially for  caries,  have  different  results  and  indications  for  each  joint. 
The  same  is  true  of  resections  of  joints  in  gunshot-wounds ;  each 
joint  has  its  special  resection  history.  Resections,  especially  resec- 
tions of  whole  joints,  are  of  much  more  recent  date  than  amputations. 
The  first  excision  of  a  carious  head  of  a  humerus  was  made  by  White, 
1768  ;  resection  of  the  elbow-joint  by  Morecnt,  1782 ;  of  the  head 
of  the  femur  by  White,  1769;  of  the  knee-joint  by  I'ark,  1762. 
But  at  first  these  operations  were  not  popular  ;  they  were  said  to  be 
too  difficult,  tedious,  and  painful,  and  it  was  thought  that  the  final 
results  would  not  be  good.  It  is  only  within  the  past  thirty  years 
that  they  have  been  accepted  by  surgeons,  and  the  methods  of  their 
performance  are  still  being  improved.  At  first  it  was  merely  at- 
tempted to  remove  the  affected  portion  of  bone  without  loss  of 
the  limb,  so  that  the  parts  might  heal.  Later,  attempts  were  made 
to  retain  the  function  of  the  false  joint  left  after  the  resection,  by 
judicious  selection  of  the  lines  of  incision,  method  of  operating,  and 
after-treatment.  Surgeons  even  went  so  far  as  to  excise  stiff  joints 
that  were  all  healed,  so  as  to  substitute  for  them  movable  false  joints. 
Possibly,  for  a  time,  we  held  too  hopeful  views  of  what  was  attain- 
able by  these  operations;  but  wonderful  cures  have  been  accom- 
plished, and  with  the  increased  attention  now  given  to  them  we  may 
expect  the  indications,  mode  of  operating,  prognosis,  and  after- 
treatment  to  be  more  defined. 

In  resections,  the  incisions  should  be  so  directed  that  no  large 
vessels  or  nerves,  and  as  few  muscles  as  possible,  may  be  injured, 
and  still  space  made  for  freeing  the  joint  and  sawing  the  bone. 


RESECTIONS.  819 

When  these  operations  were  first  done,  they  seemed  so  difficult  that 
it  was  thought  the  joint  should  be  exposed  by  large,  deep  ilaps,  so 
that  ligaments  and  muscular  insertions  could  be  readily  divided,  and 
the  ends  of  the  bones  sawed  off.  Later,  as  more  was  thought  of 
making  a  useful  joint,  the  operation  was  more  carefully  made; 
obhque  sections  of  tendons  and  large  wounds  were  avoided;  the 
periosteum  was  preserved  as  much  as  possible,  and  also  its  connec- 
tion with  the  muscular  insertions,  by  using  the  raspatorium  instead 
of  the  knife ;  and  in  chronic  inflammations  operations  were  done  in 
the  thickened  tissue,  where  they  were  followed  by  less  inflammation 
and  febrile  reaction  than  in  healthy  parts.  H.  von  Langenbeck,  more 
than  any  one,  developed  the  indications  for  resections  of  joints,  and 
perfected  the  methods  of  performing  them ;  he  also  introduced  the 
simple  longitudinal  incision,  which  is  now  generally  used  for  resec- 
tion of  the  shoulder,  elbow,  and  hip  ;  for  the  knee  an  anterior  flap 
is  made,  with  a  broad  base  above. 

The  instruments  used  for  resections,  except  the  chain-saw  (of 
Jeffray),  are  the  same  as  recommended  by  Von  L<ingenheck  :  a  strong 
knife,  five  to  seven  centimetres  long,  w4th  straight  edge  and  thick 
back  ;  this  knife  is  introduced  to  the  bone,  and  the  entire  incision 
made  at  one  stroke ;  with  a  broad,  small,  more  or  less  curved,  half- 
sharp  raspatorium,  the  periosteum  is  scraped  from  the  bone;  the 
articular  ligaments  and  some  muscular  attachments  cannot  always 
be  detached  in  this  way,  and  have  to  be  divided  close  to  the  bone. 
When  the  ends  of  the  bone  have  been  entii-ely  denuded  of  soft  parts, 
they  are  sawed  off,  being  held  by  bone-forceps,  while  the  soft  parts 
are  held  back  with  blunt  hooks.  Sharp  edges  of  bone  are  to  be 
removed  with  bone-nippers. 

Before  the  operation  the  patient  is  anaesthetized,  and  the  limb  to 
be  operated  on  is  rendered  bloodless  by  the  elastic  bandage  and 
carefully  cleansed.  After  the  operation  the  haemorrhage  is  to  be 
carefully  checked,  and  the  w^ound  washed  with  new,  clean  sponges  ; 
then  the  limb  is  placed  in  an  apparatus  to  keep  it  perfectly  im- 
movable, but  not  too  tight,  allowing  the  wound  to  be  free  and  the 
secretion  to  escape  readily ;  the  patient's  position  should  be  easy, 
and  changed  without  disturbing  the  dressing. 

I  have  not  found  it  well  to  fill  the  wound  with  charpie  and  apply 
a  bandage  before  loosening  the  pressure  above  the  wound ;  for  in  so 
doing  the  whole  bandage  is  so  filled  with  blood  that  it  must  be  soon 
renewed.  I  prefer  first  checking  the  bleeding  completely  by  liga- 
tion, acupressure,  ice-water,  etc. ;  then  I  introduce  drainage-tubes, 
dipped  in  glycerine  or  carbolic-acid  solution,  to  conduct  the  secretion 
into  vessels  placed  beneath. 


820         AMPUTATIONS,   EXARTICIJLATIOXS,   AND  RESECTIONS. 

When  possible,  I  apply  a  plaster-of-Paris  bandage  before  the 
operation,  make  openings  of  the  proper  size  at  the  point  of  opera- 
tion, then  slit  the  bandage  down  one  side  when  it  is  dry  and  remove 
it  for  the  operation,  and  have  a  plaster  shell  to  put  on  after  the 
operation,  in  which  the  limb  can  be  suspended  or  laid  on  a  Jlis''s 
supporting  splint.  Other  operators  prefer  prepared  wooden  or  iron 
splints  ;  the  same  end  may  be  attained  with  the  most  varied  ma- 
terials. After  resection  of  the  hip-joint  no  bandage  is  usually  re- 
quired, extension  by  weights  answering  the  purpose.  In  some  cases 
I  have  found  Listens  dressing  very  useful. 

Resection-wounds  are  always  rather  complicated  excavated 
wounds;  they  always  heal  by  granulation  and  suppuration  after 
a  long  time.  This  is  bad  for  resections  in  feeble,  marasraic  patients ; 
moreover,  in  such  patients  we  are  never  certain  that  caries  will  not 
attack  the  adjacent  bones  or  the  sawed  surface,  or  that  the  wound 
will  not  ulcerate. 

The  shortest  time  for  healing  after  resection  will  probably  be 
two  or  three  months.  Indolent  fistula?  often  remain  for  months  or 
years. 

Recently  great  attention  has  been  paid  to  the  final  result  of  re- 
sections of  joints.  The  resulting  false  joints  may  become  so  relaxed 
that  they  cannot  be  actively  moved,  and  the  limb  hangs  useless ; 
other  loose  joints  are  somewhat  movable  ;  then  there  are  joints 
which  have  nearly  normal  mobility  and  power  ;  and  lastly,  anchy- 
losed  joints,  which  are  nevertheless  more  useful  than  the  first  men- 
tioned. 

Tlie  final  result  depends  greatly  on  tlie  amount  of  bone  removed, 
the  amount  of  regeneration  of  bone,  the  care  observed  in  dividing 
the  muscular  insertions,  and  the  muscular  power  of  the  patient;  it 
is  also  greatly  influenced  by  gymnastic  exercises,  electricity,  baths, 
and  application  of  suitable  apparatus.  But  as  these  vary  with  the 
different  joints,  and  different  methods  and  apparatus  are  required, 
these  matters  can  only  be  explained  when  treating  of  resection  of 
individual  joints. 

Prognosis  as  regards  life  is  the  same  as  in  amputations.  Resec- 
tions on  account  of  caries  usually  run  a  more  favorable  course  than 
those  for  injuries.  The  danger  increases  with  the  proximity  to  the 
trunk.  [But  here,  even  more  than  in  amputations,  has  Listerism 
proved  beneficial.  Under  this,  and  the  treatment  by  iodoform,  the 
period  required  for  healing  is  very  much  lessened.] 


EEGISTEE  OF  ^AMES. 


PAGE 

Abemethy,  John  (f  1831,  in  London) 524 

Abulcasem  ^f  1106) 7 

Aeby  (professor  of  anatomy  in  Bern) 60 

iEsculapius 4 

Albert  (professor  of  surgery,  Innspruck) 395 

Alexander  of  Tralles  (525-605) 6 

Alexandrian  school 6 

Amabile  (professor  in  Naples) 103 

Anel,  Dominique  (surgeon  in  Turin,  beginning  of  eighteenth  century) 649 

Antyllus  (third  century) 6,  650 

Aristotle 4 

Armauer C7»t 

Arndt  (teacher  in  Greifswald) 718 

Arnold,  J.  (professor  of  pathological  anatomy  at  Heidelberg). .   70,  84,  124,  137, 

344,  658 

Asclepiades 4 

Aselli  (1581-1626) 10 

Auerbacb  (teacher  in  Breslau) 6n 

Avenzoar  (1126) 7 

Avicenna  (980-1037) 7 

Bardeleben  (professor  of  surgery  in  Berlin)   II. j 

Barensprung,  von  (1822-1864) 05 

Barton,  Rhea  (Philadelphia) 247,  612 

Bartscher  (physician  in  Westphalia) 109 

Barwell  (London  surgeon) 631 

Baum  (professor  of  surgery  in  Gottingen) 39,  74 1 

Baynton  (English  physician) 487 

Beck 282 

Becker,  Otto  (professor  of  ophthalmology  in  Heidelberg) 790 

Bell,  Benjamin  (1749-1806) 11,  145 

Bellocq,  Jean  (1732-1807) 35 

Bergmann  (professor  of  surgery  in  Dorpat) 284,  296,  395,  403 

Bernard,  Claude  (professor  of  physiology  in  Paris,  f  1878) 57 

Bernhardt,  M.  (physician  in  Berlin) 97 

Biermer  (professor  of  the  medical  clinic  in  Ziirich) 422 


822  REGISTER  OF  NAMES. 

Bilguer,  John  TJIrich  (1720-1796) 12 

Boinet  (surgeon  in  Paris) 581 

Bollinger  (of  Munich) 435 

Bonnet  (surgeon  in  Lyons,  \  1863) 13^  596 

Bouvier  (surgeon  in  Paris) CCs 

Boyer,  Baron  (1747-1833) 12 

Branca  (fifteenth  century) 8 

Brasdor  (1721-1799) 649 

Braunschweig,  Ilieronymus  (bom  1430) 10 

Brcschet,  G.  (f  1845) 640 

Breslau  (1829-1867) 423 

Breuer  (teacher  in  Vienna) 98 

Brewer,  E.  P 74 

Broca  (professor  of  surgery  in  Paris) 649 

Brodie,  Sir  Beniamin  (1783-1803) 13,  601 

Bromficld,  William  (1712-1792) 27 

Brown-Sequard  (physician  in  Paris) 126 

Briiciic,  E.  (professor  of  physiology  in  Vienna) 151,  387,  650 

Bruns,  von  (professor  of  surgery  in  Tiibingen) 35,  215,  817 

Brunschweig  (born  1430) 10 

Bubnoff  (physician  in  Russia) 133,  391 

Buck,  Gurdon  (New  York) 216,  656 

Buhl  (professor  of  pathological  anatomy  in  JIunicli) 349,  436,  442,  463 

Burow  (professor  of  surgery  in  Konigsberg) 109 

Busch  (professor  of  surgery  in  Bonn,  f  1881) 333 

Celsius 95 

Celsus,  Aulus  Cornelius  (25  b.  c.  to  45  a.  d.) 5,  6,  063 

Chassaignac  (surgeon  in  Paris) 109,  106,  525,  817 

Chauliac,  Guy  de 817 

Chcselden,  William  (1688-1793) 11 

Chiron 4 

Chopart,  Fran9ois  (1743-1795) 576 

Chrobak 98 

Ciniselli 650 

Civiale  (1792-1867) 13 

Cohnheim  (professor  of  pathological  anatomy  in  Kiel) 57,  64,  65,  206,  211, 

334,  344,  347,  364,  445,  465,  570,  634,  682 

Collin  (Paris) 44 1 

Cooper,  Sir  Astley  (1768-1841) 12,  56,  144,  759 

Coote 649 

Cruveilhier  (professor  of  pathological  anatomy  in  Paris) 381,  386,  599,  636 

Czerny  (professor  of  surgery  in  Freiburg) 103,  705 

Dalton,  J.  C,  Jr.  (New  York) 059 

Davalne  (professor  in  Paris) 404,  435,  442 

Declat  (Paris) 105,  188 

Delpech  (1772-1832) 12,  620 

Demarquay 283 

Desault,  Pierre  (1744-1795)  11 


REGISTER  OF  NAMES.  823 


PAGE 


Dieffenbach,  Johann  Friedrich  (1795-1847)..    12,39,41,47,120   142   244  245 

439,  490,  608,  624,  631,  698 

Dittle  (professor  of  surgery  in  Vienna) 139    817 

Dolschenkow  (Russian  surgeon) 379 

Dorsey  (Philadelphia,  1783-1818) 146 

Douterlepont q-jq 

Dubois-Reymond  (professor  of  phy:?iology  in  Berlin) 58 

Duchenne  (de  Boulogne)  (physician  in  Paris) , 630 

Dumreicher  (professor  of  surgery  in  Vienna) 210 

Dupuytreu,  Baron  (1778-1835) 12,  2u2,  359 

Ebert  (professor  of  diseases  of  children  in  Berlin) 372 

Eberth  (professor  of  pathological  anatomy  in  ZUrich) CO,  65,  372 

Ehrlich  (of  Vienna) 377 

Eichhorst  (of  Konigsberg) 124 

Englisch  (teacher  of  surgery  in  Vienna) 334,  654 

Eschricht  (of  Copenhagen) 615 

Esmarch,  Friedrich  (professor  of  surgery  in  Kiel) 33,  284,  430,  570,  601 

Eustachio  (f  1579) 10 

Exner  (professor  of  physiology  in  Vienna) 67 

Fabry  von  Hilden  (1560-1634) 10,  37 

Falopia(  1490-1 563) ' 10 

Fick,  Adolph  (professor  of  physiology  in  Wurzburg) 427 

Fischer  (professor  of  surgery  in  Breslau) 370,  403 

Flourens  (1791-1867) 540 

Fock,  Carl  (1828-1863) 600 

Follin  (1823-1867) 13,  508 

Fox,  Wilson  (physician  in  London) 454 

Frisch  (professor  of  anatomy,  Vienna) 372,  436 

Froriep,  Robert  (1804-1861) 127,  128,  144 

Fuchs,  E.  (professor  of  ophthalmology  in  Liittich) 68 

Galenus,  Claudius  (131-201) G 

Gersdorf,  von,  Hans  (1520) 10 

Goethe I'j 

GoU  (physician  in  Ziirich) 425 

Golubew  (Russian  physician) ^'^ 

Graefe,  von,  Carl  Ferd.  (1787-1840) I'-i,  -t'^ 

Graefe,  von,  Albrecht  (professor  of  ophthalmology  in  Berlin) 430 

Gross,  S.  D.  (professor  of  surgery  in  Philadelphia) 247,  612 

■  Gross,  S.  W.  (of  Philadelphia) J519 

Guido  de  Cauliaco  (fourteenth  century) S 

Gurlt  (professor  of  surgery  in  Berlin) 203 

Gussenbauer  (professor  of  surgery  in  Liege) <>8,  122,  158,  334,  798 

Guterbock  (of  Berlin) 68 

Ilalford  (of  Australia) ^^^ 

Ilaller,  von,  Albrecht  (1708-1 777) ^  - 

Hallier  (professor  of  botany  in  Jena) 1 1 ' 

Hansen 


824  REGISTER  OF  NAMES. 

PAGE 

Harvey,  William  {U18-U5S) 10,  470 

Hebra  (professor  of  dermatology  in  Vienna,  f  1S80) 291 

Heiberg  (of  Christiania) 83 

Heine,  Bernliard  (instrument-maker  and  honorary  pi-ofessor  of  surgei'y  in  Wiirz- 

burg,  contemporary  with  Cajetan  von  Tcxtor) 383,  540 

Heis,  C 659 

Heister^  Lorenz  (1683-1758) 12,  758 

Heitzmann  (of  New  York) 460 

Hcmsbach,  H.  M  von 520 

Henke  (of  Tiibingen) 619 

Henle  (professor  of  anatomy  in  Gottingen) 59,  60,  604 

Hennen,  John  (f  1828) 274 

Hcring  (professor  of  physiology  at  the  Josephs  Academy,  Vienna) Gl 

Hertwig 666 

Hildanus,  Fabricius 10,  39 

Hippocrates  (460-377  b.  c.) 4,  418,  662 

Hjclt  (physician  in  Sweden) 123 

Hood,  Wharton  P.  (of  England)  611 

Howard,  B.  (of  New  York) 104 

Howship  (English  surgeon) 501 

Hueter  (professor  of  surgery  in  Greifswald) 42,  257,  415,  417,  466,  569,  619 

Hufschmidt  (physician  in  Silesia). 97 

Hunter  (1728-1 793) 11,  13,  134,  417,  649 

Hutchinson  (surgeon  in  London) 772 

Jackson  (physician  in  Boston) 13 

Jacobson  (professor  in  Konigsberg) 97 

Jeffray 819 

Jobert  (de  Lamballe)  (1739-1863) 13 

Jochmann  (f  physician  in  Prussia) 184 

Kassowitz  (teacher  in  Vienna) 552 

Kern,  von,  Vincens  (1760-1829) 12 

Key,  Axel  (professor  of  pathological  anatomy  in  Stockholm) 65,  683,  706 

Kilian  (of  Prague) 506 

Klebs  (professor  of  pathological  anatomy  in  Bern) 285,  466,  760 

Koch,  Robert 415 

Kocher  (professor  of  surgery  in  Bern) 333 

Kochmann  (of  Strasburg) 322 

Koeberle  (professor  of  surgery  in  Strasburg) 33 

Kolliker  (professor  of  anatomy  in  Wurzburg) 659 

Koster  (teacher  of  pathological  anatomy  in  Wiirzburg) 707 

Krause  (professor  in  Hanover) 137 

Kiihne  (professor  of  physiology  in  Amsterdam) 520 

Kundrat  (professor  in  Gratz) 349,  460 

Laenncc  (1781-1826) 463 

Lambl  (professor  in  Kharkov) 773 

Lanfranchi  (f  1300) 8 

Langenbeck,  Conrad  Martin  (1776-1850) 12,  15,  137 


REGISTER   OF  NAMES.  825 

PAGE 

Langenbcclv,  von,  Bernhard  (professor  of  surgery  in  Berlin). .  139,  245,  281    430 

570,  608,  628,  650,  797,  819 

Langhaiis  (professor  of  patholog?cal  anatomy  in  Bern) 459 

Larrey,  Jean  Dominique  (1766-1843) 12    274 

Laudien  (pliysician  in  Konigsberg) 97 

Lawrence,  Sir  William  (1783-1867) 13 

Leber  (Gottingen) 3'72 

Lebert  (professor  of  the  medical  clinic  in  Breslau) 7I6 

Leiter  (of  Vienna) 522 

Leroy  d'Etiolles  (1798-1861) 13 

Letheby  (of  England) 437 

Leube  (Erlangen) 435^  442 

Leyden  (professor  of  the  medical  clinic  in  Konigsberg) 96    427 

Liebermeister  (professor  of  the  medical  clinic  in  Basel) 96    422 

Liebreich  (professor  of  medicine,  Berlin) 21 

Lincoln,  R.  P.  (of  New  York) 650 

Linhart,  von  (professor  of  surgery  in  Wiirzburg) 586,  818 

Lister  (professor  of  surgery  in  Glasgow) 110,  113,  180,  238,  524,  525 

Livingstone  (African  explorer) 437 

Lorinsen  (of  Vienna) 619 

Losch  (physician  in  St.  Petersburg)   93 

Lessen  (professor  of  surgery  in  Heidelberg) 211 

Lotze  (professor  of  philosophy  and  medicine  in  Gottingen) 58 

Lowdham  (1679) 817 

Llicke  (professor  of  surgery  in  Bern) 333,  370,  631,  677,  741,  750,  760 

Lukomsky  (army  surgeon  in  Russia) 377 

Luschka,  von  (professor  of  anatomy  in  Tiibingen) 753 

Malgaigne  (1806-1865) 13,  260,  265,  648 

Martin  (professor  of  obstetrics  in  Berlin,  f  1S76) 41 

Maslowsky  (professor  in  St.  Petersburg) 122 

Masquelin  (professor  in  Liittich) 666 

Matthysen  (army  surgeon  in  Holland) 214 

Meckel  von  Hemsbach  (1821-1856) 665 

Menel  (regimental  surgeon  in  Saxony  at  the  beginning  of  this  century) 247 

Menzel  (of  Trieste)   103 

Meyer,  H.  (professor  of  anatomy,  Ziirich) 617 

Meynert  (teacher  in  Vienna) 425 

Middeldorpf  (professor  of  surgery  in  Breslau,  1824-1SG8) 13,  28,  39 

Minnich  (of  Venice) 103,  115 

Mondino  de  Luzzi  (fourteenth  century) 8 

Monro,  Alexander  (1696-1767) 1 1 

Morant  (of  France) 551 

Moreau  (1782) 81 3 

Morton  (dentist  in  Boston) 1  -^ 

Mosetig-Moorhof  (surgeon  in  Vienna) 467 

Mott,  Valentine  (1785-1865) 13 

MuUer,  Johannes  (1801-1858) 660,  681,  693,  733 

MuUer,  Max  (physician  in  Cologne) 218 

Miiller,  W.  (professor  of  pathological  anatomy  in  Jena) 436,  442 


826  REGISTER  OF  NAMES. 

PAGE 

Nassiloff  (of  St.  Petersburg) 372 

Nedopil  (teacher  of  surgery  in  Vienna) 605 

Nestorians 7 

Neudorfer  (army  surgeon  in  Vienna) 42 

Neumann,  J.  (of  Kiinigsberg) 124,  322 

Niemeyer,  yon,  Felix  (professor  of  medical  cfinic  in  Tiibingen) 459,  464 

Oilier  (pbysician  in  Lyons) 540 

Oribasius  (326-403) 6 

Orth  (Berlin) 372,  377 

Panum  (professor  of  physiology  in  Copenhagen) 41,  393,  404 

Paquelin  (of  Paris) i 34 

Paracelsus,  Bombastus  Thcophrastus  (1493-1554) 10 

Pare,  Ambroisc  (1517-1590) 11,  27,  280 

Park  (1 762) 818 

Pasteur  (professor  of  chemistry  in  Paris) 105,  110,  113,  404,  441 

Paulus  ab  yEgina  (660) 6 

Percy,  Pierre  rran9ois  (1754-1825) 11 

Petit,  Jean  Louis  (1074-1760) 11,  32 

Petrequin  (surgeon  in  Lyons) 049 

Pfleger  (physician  in  Vienna) 374 

Pf olsprundt  (middle  of  the  fifteenth  centurj^) K ) 

Piorry  (professor  of  medicine  in  Paris) 408 

Pivogoff,  Nicolaus  (professor  of  surgery  in  Russia) 214,  274,  278,  523,  576 

Pitha,  von  (professor  of  surgery  at  the  Josephinum  in  Vienna) 370 

Plato 4 

Ploucquet  (1744-1814) 817 

Pollender 435 

Polli  (professor  in  Padua) 422 

Ponfick  (professor  in  Breslau) 289,  290 

Porta  (professor  of  surgery  in  Pavia) 134,   135,  136,  143 

Pott,  Percival  (1713-1788) 11,  513 

Pravaz  (f  physician  in  Lyons) 649 

Purmann,  Gottfried  (about  1679) 11 

Pythagoras 4 

Ravaton  (middle  of  eighteenth  century) 817 

Raynaud  (French  jihysiciiin) 360 

Recklinghausen,  von  (professor  of  pathological  anatomy  in  Wiirzburg).    61,  65, 

80,  133,  391 

Redf ern  (English  physician) 65 

Reverdin  (of  Geneva) 73,  103,  672 

Reiclicrt  (professor  of  anatomy  in  Berlin) 659 

Remak,  Robert  (f  1865) 349,  659 

Retzius  (professor  in  Stockholm) 683 

Reyher  (teacher  in  Dorpat) , 284 

Rhazes  (850-932) 7 

Richardson  (physician  in  London) 20 

Richter,  Aug.  Gottlieb  (1742-1811) 12 


REGISTER   OF  NAMES.  §27 


PAGE 


Ricord  (surgeon  in  Paris) 

Riedel  (Gottingen) y^j 

Rindfleiscb,  Eduard  (professor  of  pathological  anatomy  in  Bonn). .  62,  116,  131 

349,  459,  506,  675,  703,  709,  715,  747^  700 

Ris  (physician  in  Ziirich) 217 

Robin  (professor  of  anatomy  in  Paris) 721    762 

Rokitansky  (professor  of  pathological  anatomy  in  Vienna). .   70,  125,  425    552 

680,  688,  709 

Rose,  E.  (professor  of  surgery  in  Ziirich) 424    750 

Rosenbach  (Gottingen) 3;;3 

Rosenberg  (Wiirzburg) 74 

Roser  (professor  of  surgery  in  Marburg) 270    3;j3    442 

Roux  (1780-1854) '.....'     13 

Rush 480 

Rust,  John  Nepomuk  (1775-1840) 12,  493,  5G2 

Salernian  school 7 

Salomonsen 465 

Samuel  (Konigsberg) 66,  106,  295,  344,  347,  364 

Sands,  H.  B 468 

Sattler  (professor  of  ophthalmology  in  Giessen) 725 

Scarpa  (1748-1832) 11 

Schiff  (professor  of  physiology  in  Florence) 58,  123 

Schmidt,  Alexander  (professor  in  Dorpat) G7,  118 

Schneider  (Saxon  army  surgeon,  beginning  of  this  century) 247 

Schneider  (physician  in  Konigsberg) 96 

Schonlein,  Lucas  (1793-1864) 680 

Schuh,  Franz  (1804-1866) 13,  728,  787 

Schuller 408,  560 

Schulze,  Max  (professor  of  anatomy  in  Bonn) 80 

Schupple  (Tubingen) . .    459,  463 

Schwalbe  (of  Weinheim) G54,  750 

Schwann  (professor  of  physics  in  Liege) 125,  658 

Scoutetten  (professor  in  Paris,  1830) 818 

Scultet  (1595-1645) 214 

Senator  (physician  in  Berlin) 96 

Seutin,  Baron  (1793-1862) 13,  215,  218 

Siebold,  von,  Carl  Caspar  (1736-1807) 12 

Silvestri,  Grandesso 33 

Simon  (professor  of   surgery  In  Heidelberg,  f  1876) 46 

Simpson,  Sir  James  Y.  (professor  of  obstetrics  in  Edinburgh) 13,  35 

Sims  (of  New  York) "'? 

Skutsch  (physician  in  Silesia) 2iH 

Smith,  Nathan  (Baltimore) 217 

Soborow  (of  Moscow) ^^"^ 

Sonnenberg  (of  Strasburg) 289 

Sonnenschein ^^ 

Sprengel  (1766-1833) 818 

Stanley  (1791-1862) 13 

Starcke ^^^ 


828  REGISTER  OF  XAMES. 

PAGE 

Stein,  Alex,  (of  New  York) 104 

Steudener  (teacher  of  pathological  anatomy  in  Ilalle) 311 

Stiirk  (professor  in  Vienna) 751 

Strieker,  Salomon  (prof  essor  of  general  pathology  in  Vienna) .   61,  65,  395,  404,  449 
Stromeyer  (formerly  professor  of  surgery  in  Freiburg,  Munich,  Kiel,  staff-physi- 
cian in  Hanover) 142,  274,  369,  372,  417,  601,  624 

Susrutas  (first  century  ?) 4 

Swaen  (professor  of  anatomy  in  Liittich) 666 

Sydenham  (1624-1689) 470 

Syrae  (profe^^sor  of  surgery  in  Edinburgh) 651 

Szymanowsky  (professor  of  surgery  in  Kiev,  1868) 215 

Taylor  (of  Xew  York) 568 

Textor,  von,  Cajetan  (1782-1860) 12,  422 

Theden,  Chr.  Ant.  (1714-1797) 12,  34 

Thiersch  (prof essor  of  surgery  in  Leipzig). .. .   68,  90,  103,  115,  132,  349,  659, 

674,  677,  760,  769 

Tillman  (professor  in  Leipzig) 69,  257,  382,  384 

Toldt  (professor  in  Prag) 692 

Toussaint 441 

Traube  (professor  of  the  medical  clinic  in  BerUn) 95,  96,  184 

Troja,  Michcle  (1747-1827) 540 

Trousseau 739 

Trotula  (twelfth  century) 7 

Tschausoff  (Russian  physician) 134 

Valsalva  (1666-1723) 648 

Vanllekc 421 

Vanzetti  (professor  of  surgery  in  Padua) 33,  648 

Velpeau  (1795-1867) 13,  787 

Verduin  (1696) 817 

Vermale  (French  surgeon,  middle  of  last  century) 817 

Verneuil  (professor  of  surgery  in  Paris) ....  33,  689,  747 

Vesalius,  Andreas  (1513-1564) 10,  11 

Vezin  (of  Westphalia) 109 

Vidal  (de  Cassis)  (end  of  the  last  century) 637 

Villemin  (physician  in  Paris) 465 

Virchow  (professor  of  pathological  anatomy  in  Berlin). .  .58,  62,  119,  207,  211, 
349,  382,  386,  391,  393,  415,  418,  449,  472,  501,  520,  656,  664,  673,  678, 

696,  705,  759 
Volkmann,  Rich.  (i)rofessor  of  surgery  in  Halle).    10.5,  189,  237,  311,  337,  501, 

505,  516,  524,  579,  587,  605,  621,  631,  760 

Wagner,  A.  (professor  of  surgery  in  Konigsberg) 246,  540 

Wagner,  E.  (professor  in  Leipzig) 472 

Waldenberg  (teacher  of  medicine  in  Berlin) 454 

Waldeyer  (professor  of  pathological  anatomy  in  Breslau) 659,  677,  718,  760 

Waller,  Aug.  (English  surgeon) 64 

Walther,  von,  Philipp  (1782-1849) 12 

Wardrop  (f  English  surgeon) 649 


REGISTER  OF  NAMES.  829 

PAGE 

Weber,  Otto  (182Y-1S6Y)....    13,  97,  121,  129,  181,  393,  403,  415,  520,  656, 

673,  697 

Wegner  (teacher  in  Berlin) 211,  243 

Weller  (England) 439 

Wells,  Spencer  (surgeon  in  London) 2(i,  190,  421,  687 

Wernher  (professor  of  surgery  in  Giessen) 601,  786 

Wertheiiu  (physician  in  Vienna) 289,  493 

White  (1769)  818 

Winiwater,  A.  von  (teacher  in  Vienna) 365,  742 

Winiawater,  Felix 68 

Wolff,  J.  (of  Berlin) 210,  540 

Wunderlich  (professor  of  the  medical  clinic  in  Leipzig) 95 

Wurz,  Felix  (f  1567) 10 

Wutzer  (1789-1860) 13 

Wyss,  0.  (professor  of  the  polyclinic  in  Ziirich) 454 

Wy wodzoff  (physician  in  St.  Petersburg) 90 

Zaleski  (professor  in  Kharkov) 676 

Zeis(f  1868) 74,  487 

Zenker  (professor  of  pathological  anatomy  in  Erlangcn) 320,  756 

Ziegler  (of  Wurzburg) 69 

Ziemsen  (professor  of  the  medical  clinic  in  Erlangen) '. 630 

Zuelzer 404 


IISTDEX. 


Abdoraen,  eontusion  of,  167. 

Abiogenesis,  HI. 

Abscess,  79,  157,  316;  of  bone,  509;  cold,  446; 
confi^estive,  447 ;  of  kidneys,  S!»3 ;  of  liver.  -MS ; 
metastatic,  394 ;  periarticulai-,  254;  subcutane- 
ous puncture  of,  526. 

Academy  of  Surgery.  11. 

Acetiite  of  aiuujina,"36;i. 

Aconite  in  {-yiemia,  422. 

A  corn-coft'ee,  45s. 

Acupressure,  85, 188. 

Acupuncture,  IMs. 

Acute  articular  rheumatism,  340. 

Adenoma,  731,  74(). 

Adeno-sarcoma,  781. 

Adlicsive  plaster,  44;  to  favor  absorption,  318  ;  in 
ulcers.  487. 

Advanci  d  ajre  as  a  cause  of  tumors,  674. 

A!J:ui-Ve(la,  8. 

Air,  entrance  of,  into  veins.  23. 

Alveolar  formation  as  a  peculiarity  of  cancer,  759. 

Ambulances.  277. 

Amoeboid  movements,  '0. 

Amputation,  22.">,  HU;  for  eransrene,  364  :  for  py- 
aemia, 427;  for  osteomyelitis,  381). 

Amyloid  defjeneration.  520. 

Anwmia  causing  gangrene,  360. 

Anaesthesia,  local.  20. 

Anaesthetics,  13,  20. 

Anchylosis,  602;  cartilaginous,  605;  extension  of; 
602;  osseous,  612. 

Aneurism,  143,  638 ;  dissecting.  145 ;  of  the  ex- 
tremities, 645;  spurious  or  traumatic,  148;  va- 
ricose, 146;  cirsoid,  by  anastomosis,  racemose, 
639 ;  cylindriform.  fusiform,  sacculated,  643. 

Aneurismal  varix,  7(16. 

Angioma,  706  ;  cavernous,  708. 

Angio-sarcoma,  724. 

Anthrax,  806,  484. 

Antiseiitics,  10,5,  114. 

Antrum  Highmori,  cysts  of,  758 ;  cancer,  7S7. 

Apoplexy,  152. 

Aqua  Bi'nelli,  39. 

Arnica,  160. 

Arterial  thrombosis,  357. 

Artery,  contraction  of,  from  cold,  295 ;  healing  of 
wounds  of,  142 :  hook,  27 ;  ligation.  27 ;  mediate 
ligation  of.  28;  percutaneous  mediate  ligation, 
28;  rupture  of,  in  open  Iractures,  224 ;  torsion 
of,  29 ;  contusion,  174, 

Arthrite  seche,  .5^9. 

Arthritis,  842,  469 :  deformans,  593. 

Arthrorace,  562. 

Arthrocacologie,  562. 

Asklepiades,  4. 

Asphyxie  locale.  853. 

Atheroma,  470,  642. 


Bacteria.  111. 

Baker's  leg,  618, 

Barbers  and  bathers,  9. 

Baths,  458,  479,  595. 

Beating  exi>eriment,  167. 

Bed  sore,  856.  865. 

Be/loc^s  sound,  37. 

•'  Black  eye,"  1.54. 

Bladder,  cancer  in,  763. 

Bleeding  in  delirium  tiemcns,  429. 

Blennorrha-a,  818. 

Blisters,  476. 

Blood-clot,  119;  frozen.  295. 

Bloodless  ojieratious,  33. 

Blood-vessels,  dilatation  of,  57. 

Blue  milk,  8Tii;  pus.  870. 

Bone,  corpuscles,  207  ;  abscess  of,  509;  absorption 

of,   246 ;   atrophy  and   hypertrophy.  508,  552 ; 

exercise,  7(t2;  fracture  ot,  195;  fissure  of,  197; 

iKllammatiou  of.   824;    reabsorptioh  of,    207; 

tidjercles  in,  508;  regeneration,  528;   setting, 

(-.11, 
Book  of  the  Art  of  Life,  3. 
Brain-sand  tumor.s,  721. 
Brisement  forc6,  607. 
liromJifld^H  artery-hook,  27. 
Bullet-forceps,  281. 
Burns,  286. 
Burnt  sponge,  458. 

Buroa'K  fluid,  see  acetate  of  alumina. 
Bursa,  diopsy  ol,  5&5. 

Cachexia,  cancerous,  782. 

Cadaveric  poison.  431. 

Calculi,  vesical  and  renal,  470. 

Callus,  20lt. 

Cancer,  758;  atrophying,  779;  of  bladder,  708; 
of  bone,  762;  cauliflower.  772;  colloid,  gelati- 
nous, 7C8  ;  en  cuirasse,  767  ;  epithelial,  7tj5  ;  of 
hand,  778  :  lenticular,  767  ;  of  skin,  772  ;  villous, 
774;  stomach  and  duodenum,  78V:  lachrymal, 
salivary,  and  i)rostate  glands,  790 ;  inam- 
mary,  775;  thyroid  gland  and  ovary,  791  ;  of 
lij),  674;  papillary,  761;  transplantation  o^ 
799. 

Cancroid,  765, 

Canine  madness,  4.37. 

Carbolic  acid.  368,  385. 

Carbuncle,  806,  322,  434. 

Carcinoma,  75;*. 

Carcinosis,  791. 

Caries,  498, 50.5. 

Cartilage-tumors,  694. 

Caseous  degeneration,  448. 

Cataplasms.  170. 

Catarrh,  310. 

Catching  cold,  180,  801,  672. 


INDEX. 


831 


Caustics  for  cancer,  795. 

Cautery,  actual,  36  ;  iron,  477. 

Cavernous  venous  tumors,  708 ;  lymphatic  tumors, 
718. 

Cells,  wandering',  Gl . 

Cellular  tissue,  uiflammation  of,  cellulitis,  312. 

Cephalha?inatoma,  154. 

Cerebri,  compressio,  contusio,  150. 

Chalky  concrement,  44y. 

Chancre,  471. 

Chaps,  158. 

Chemical  ferments,  180. 

Chicken-breast,  547. 

Chilblains,  298. 

Chill,  183,412. 

Chinese  silk,  46. 

Chiragra,  430. 

Chirurgerv,  3. 

Chloride  of  zinc,  796. 

Chloroform,  13. 

Chlorosis,  gangrene  in,  360. 

Cholesteato.na,  753. 

Chondromata,  094. 

Choroidal  tubercle.  .559. 

Cibotium  Cunninghii,  34. 

Cicatricial  islands,  2S8. 

Cicatrix,  77;  deformities  caused  by,  622 ;  opening 
of,  120. 

Cicatrization,  77. 

Cinnabar  method,  122,  251. 

Circulation,  collateral,  54 ;  plasmatic,  73. 

Cirrhosis,  mamma;.  7S6. 

Cirsoid  aneurism,  639. 

Clap,  812. 

Cla\iele,  fibromata  on,  6S8. 

Cloaca,  534. 

Club-foot,  614. 

Coal-dust  in  lungs,  403. 

Coccobacteria,  111. 

Coecygei,  tumores.  755. 

Coek's-co::ib-like  vegetations,  684. 

Cod-liver  oil,  458. 

Cold  abscess  communicating  \vilh  diaphyses,  527; 
joint,  343. 

Collateral  circulation,  .54, 136. 

College  of  St.-Come,  9. 

Collodion,  44. 

Collonema,  719. 

Comedo,  7.52. 

Compression,  of  arteries,  3D ;  of  brachial,  31  ;  ca- 
rotid, 30;  femoral,  32;  subclavian,  al;  of  vari- 
cose veins,  6)8;  of  lymphoma,  741 ;  as  mode  of 
treatment,  474,  64S. 

Concussion  of  nerves,  150,  -SiS. 

Condylomata,  471. 

Congestion,  50. 

Connective-tissue  corpuscles,  61 ;  tumor,  634. 

Contagion,  405. 

Contusion  by  bullets,  275 :  of  nerves  .and  vessels, 
151 ;  of  sott  parts  without  wounds,  14J. 

Cooper,  12. 

Cordova  school,  7. 

Cornea,  wound  of,  87. 

Corpuscular  elements,  798. 

Counter-extension,  212. 

Crepitation,  198. 

Croton-oil.  476. 

Croupous  inflammation,  312. 

Curare,  439. 

Curvature  of  spiYie,  548. 

Cutis  pendula,  684. 

"     acute  inflammation  of,  304. 

t'ylindromata,  725, 740. 

Cyphosis,  617. 

Cyst,  156;  neoi)lastic,  754;  ot  ovary,  testicle, 
breast,  754 ;  retention,  secretion,  752 ;  contain- 
ing foetus,  blood.  721. 

Cysticercus  eellulosa',  756, 

Cystoma,  7.52. 

Cysto-sarcoma,  752. 


Dead  bone  absorbed,  245. 

Decomposition,  110. 

Decubitus,  356. 

Deformities  from  cicatrices,  622. 

Delirium  nervosum,  42y ;  potatorum,  in  open 
fracture,  428. 

Derivatives,  475. 

Desmoid  tumors,  685. 

Development  of  body.  615. 

Diabetes  niellitus,  carbuncle  in,  309 ;  cause  of 
g.angrene,  361. 

Diapcdesis.  S46. 

Diapliyses,  disease  of,  326. 

Diathesis  (see  Dyscrasia). 

Ditffenbacli'H  operation  lor  false  joint,  244. 

Digitalis,  422. 

Diphtheria,  312,322;  of  wounds,  118;  traumatic, 
urinary,  372. 

Dislocation,  200  ;  of  hip,  jaw,  shoulder,  206; 
haljitual,  200;  complicated,  208;  congenital, 
209. 

Dissecting  wounds,  431 ;  tubercles,  C69. 

Distortion  of  joint,  250. 

'•  Doctor,"  7. 

Dolores  osteocopi,  497. 

Double  joint,  547. 

Drainage-tubes.  109.238,525. 

Dropsy  of  the  joint,  578. 

Drunkard's  mania,  428. 

Drunkenness,  424. 

Dynamometer,  265. 

Dyscrasia.  diathesis.  453 ;  cancerous,  679  ;  scrofu- 
lous, 459  ;  tuberculous,  45!) ;  tumor.  679. 

Dysmorphosteopalinklastes,  246. 

Ear,  haemorrhage  from,  641 ;  rings,  120. 
Ecehondrosis  ossificans.  700. 
Ecchymosis,  ecchymoma.  153. 
Echinococcus  houiinis,  756. 
Ecrasemeut,  106,691. 
Ecraseur,  160. 

Eczema  solare,  202 ;  eczema  of  leg,  C35. 
Eliistic  ligature,  091. 
Electricity  for  contractions,  630. 
Electropiincture.  244.  650. 
Elephantiasis,  446,  085, 703. 
Embolhaemia  41.5. 
Embolism.  359. 305. 386, 392. 
Embryonal  cells,  666. 
Emetics,  379. 
Emplastrum  cerupsip.  44. 
Empyema  of  joint,  337. 
Enciphaloid.  720. 
Enehondroma.  584. 
Endocarditis  causing  gangrene,  360 
Endothelium,  70S. 
English  disease,  545. 
Enroulcment  of  varicose  veins,  687. 
Epileptiform  spasms,  142. 
Episiohsematoma,  154. 
Episiorrhagia,  154. 
Epistaxis,  87. 
Epithelial  cancer,  765. 
"         pearls,  76->. 
EpitheliiHii,  development  of,  77. 
Epulis,  730. 
Erectile  tumor.  706. 
Erethitic  granulations,  117. 
Er?otiM,  090. 
Ergotism.  301. 
Erysipelas.  179;   ambulans.  874:  bullosnm,  875; 

capitis.  a7S;  traumatic.  8i>4. 873. 
Kt»iiir<;li''M  bandage,  83  ;  wound-doucho,  102. 
Ether.  18. 

Exanthemata,  acute,  804. 
E.xcoriation.  15:?. 
Exostoses.  C)[)'i. 
Extension.  212.  216. 
Extravasations  of  blood,  34;  reabsorption  of,  155; 

su])puration  of,  150. 


832 


INDEX. 


False  joint,  208,  241. 

Farcy,  483. 

Fascia,  division  of,  628. 

Fat  embolism,  235. 

Fatty  tumors,  GU2. 

Febrile  reaction,  182. 

Felon,  312. 

1'  emale  pupils,  7. 

Fever,  390 ;  hectic,  450 ;  septic,  402 ;  suppurative, 
ls3,  408  ;  putrid,  183;  from  constipation,  401 ; 
traumatic,  tfo,  1&3,  220, 397. 

Fibrine,  35il. 

Fibroma,  fibrous  tumors,  684;  pigmented,  684. 

Figure,  9,  438. 

Fingers,  choudromata  of,  697. 
'•        tenotomy  in,  027. 

Fire-arms  first  used,  273. 

Fire-mole,  714. 

Fistula,  117,448. 

Flat-foot.  01 7. 

Flexion  of  limbs  as  hicmostatic,  34, 

Fluctuation,  153. 

Fluxion,  50. 

Flying  hospitals,  278. 

Fontanel,  477. 

Forced  extension,  246. 

Formative  cells,  658. 

Fracture-bo.x,  217. 

Fractures  of  bones.  105 ;  causes,  196  ;  compli- 
cated. 222  ;  gunshot,  273;  open,  222  ;  progno- 
sis of,  228;  of  thigh.  224;  of  olecranon,  patella, 
242 ;  obliquely  united,  246 ;  reduction  of,  212 ; 
symptoms,  197;  varieties,  197. 

Fragilitas  ossium,  196. 

Fragments  of  bone,  reposition  of,  212. 

Freckles,  684. 

Freezing,  general,  297. 

Friction -sound,  586. 

Fro.st-bite,  293. 

Furunculosis,  305. 

r,.alvano-caustic,  39,  691. 

Ganglion,  582. 

Gangrene,  108,  853  ;  hospital,  863  ;  from  com- 
pression, 856 ;  senile,  357 ;  g.  noiocomialis,  368. 

Gastric;  catairh,  673. 

Gelenkmaus,  .598. 

Generatio  acquivoca,  64,  111. 

Geneva  convention,  279. 

Genu  varum,  54S;  valgum,  518. 

Germ-lavers,  666  ;  tissue,  62. 

Giant-cells,  459, 

Glanders,  438. 

Gliosarcoma.  715. 

Globules  epidemiques,  70S. 

Goitre,  749. 

Golz's  experiment,  153,  167. 

Gomarthrocace,  502. 

Gonorrhoea,  471. 

Gout,  469. 

Granular  cells,  !-S. 

Granulations.  76;  diseases  of,  116;  croup  of,  118; 
erethitic,  117  ;  fungous,  110. 

Granulation  tissue,  02 ;  g.  stage  of  tumors,  050. 

Gravel,  470. 

Grog,  429. 

Griitzboutel,  753. 

Gummy  tumors,  472. 

Gunshot-wounds,  273. 

Gutta-percha  splints,  215,  220, 

Gymnastics,  630. 

Ilaemarthron,  249. 
Hajmatodes,  706. 
Ha^matoidin,  155. 
Htematoma,  153. 

Ilnemato-thorax,  pericardium,  154. 
Ilsemophilen,  24. 

Hsemorrhage,  21 ;  arterial,  22 ;  capillary.  21  : 
trom  contused  wounds,  165;   from  gunshot- 


wounds,  284  ;  from  pharynx,  posterior  nares, 
rectum,  25, 37 ;  parenchyinatous,  24,  176:  pul- 
monary, 4S3;  subcutaneous,  151;  venous,  23, 

Ha-morriiagic  diathesis,  hsemophilen,  24. 

Haemorrhoids,  636. 

Hemostatics,  27 ;  cold  and  heat  as,  34,  237. 

Hail-  in  moles,  714. 

Halisteric  atrophy  of  bone,  506. 

Hare-lip  suture,  4S. 

Healing  by  first  intention,  51 ;  by  first  and  sec- 
ond intention,  107. 

Heart's  action,  158. 

Heat,  570. 

Hectic,  450. 

Helkologie,  493. 

Herba  jacea,  458. 

Hereditiiry  infltience,  458,  46:3,  635,  604. 

Hernia,  doctors,  9;  mortification  La  strangulated, 
856. 

Heterochronic,  665. 

Heterotopic,  665. 

Horny  excrescences,  744. 

Hospital  gangrene,  118, 179. 

Hospital,  field,  278, 

Housomaid'.s  knee,  322,  586. 

Ilumoi'alists,  301 ;  view  of  tetanus,  420. 

Hyalinose,  520. 

Hydrargyrosis,  472. 

Hvdrartlirus,  578. 

Hydrate  of  chloral,  21. 

Hydrocele,  581. 

Hydrophobia.  437. 

Hydrops  articulorum,  8C6  ;  genu  acutis,  8SG ; 
chronicus,  554,  578. 

Hygroma  pra'patellaris,  587. 

Hyperwinia,  56. 

Hj'perplasia.  445. 

Hypertrophy,  44.5.  656 ;  homcoplastie,  hetero- 
plastic, hyperplastic,  056. 

Hypersecretion,  446. 

Hypodermic  injections,  21. 

Hystricisnms,  745. 

Ice  in  inflammation,  475. 

Ichor,  415. 

Ichora'mia,  415,  418. 

Ichthyosis,  745. 

Icterus  from  snake-bite,  401. 

Indifferent  cells,  658. 

Infarctions,  892,  409. 

Infectious  diseases,  185. 

Infiltration,  cellular  or  plastic.  62 ;  oedematous,  62. 

Inflammation,   traumatic,    49,    84;    of   contused 

wounds,   178;    phlegmonous,  812;    secondary, 

177,  444;  tumors,  602;  of  wounds,  80;  chronic, 

444. 
InflaiTimatorv  new  formation,  02. 
Infraction,  197,  246,  547. 
Injections  of  iodine,  581,  741,  751. 
Insects,  poison  from,  430. 
Insolation,  292. 
Iodoform,  240,  407. 
Ischa;mia,  392. 
Isinglass-plaster,  43. 
Itch,  452. 
I  vorj',  exostosis,  700 ;  pegs  used  in  pseudarthrosis, 

244,50'. 

Jaundice  (me  Icterus). 

Joint  mouse,  .598. 

Joints,  catarrhal  inflammation  of,  835 ;  cold  ab- 
scesses communicating  with,  !548  ;  contusion  of, 
249  ;  dropsy  of,  57s  :  inflammation  of,  251, 335; 
gonorrhfeal  inflammation,  342 :  pyjeuiic,  84'i ; 
metast.atie,  84;i ;  puerperal,  343  ;  'flexed  posi- 
tion of,  2.54  ;  loose  bodies  in,  .598 ;  movements 
of,  005  ;  neuroses,  001 ;  openings  of.  251 :  pene- 
trating wounds  of,  251;  stiff,  604;  scrofiilous 
inflammation  of,  5.55;  syphilitic,  597;  tapping, 
580 ;  treatment  of  inflamed,  255. 


INDEX. 


833 


Knee-joint,  inflammation  of,  336. 
Knitting-needle  as  loreign  body,  138. 
Knocls-Jtnee,  619. 

Laced-stocljing,  638. 

Lactic  acid,  207. 

Lacunar  corrosions,  501. 

Lurdaceous  deposit,  449. 

Laoatiasis,  6S4. 

Lsucin,  99,  101. 

Laucocythemia,  739. 

Li?  iments,  division  of,  623. 

Ligation  of  arteries,  27,   649;    mediate,  28;   of 

polypi,  690;  of  telangiectases,  711. 
Ligature,  27 ;  rods,  35. 
Lightning-stroke,  293. 
Liine,  243. 

Line  of  demarcation,  168,  855,  863. 
Lipoma,  692. 

Liquid-glass  dressings,  213. 
Liquor  ferri  sesquishlorati,  39,  649. 
Lister^s  dressing,  113. 
Local  Infection  of  tumors,  669. 
Locus  minoris  resisteatiae,  180,  301. 
Loxarthroses,  614. 
Lupus,  490. 
Luxation,  260 ;  old,  267 ;  inter  partum  acquisitte, 

26J. 
Lymphangioma  cavernosum,  713. 
Lymphangitis,  179,  379. 
Lymphatic  glands,  disease  of,  736. 

"  vessels.  Inflammation  of,  379. 

"  diathesis,  455. 

Lymphatics  in  synovial  membranes,  254. 
Lymphoma.  730. 
Lympho-sarcomata,  737. 
Lyssa,  437, 439. 

Maeroglossia,  718. 
Maggot,  752. 
Maliasma,  433. 
Mahgnant  carbuncle,  306. 
lymphoma.  737. 
Malum  senile  coxoe,  533. 
Mamma,  cancer  of,  775. 
Manipulation,  623. 
Manus  vara,  616. 
Marasmic  thrombus,  888, 
MavtMs  bandage,  493. 
Massage,  250,  474,  478,  587 
Match-maker's  poisoning,  539. 
Mediate  ligation,  28. 
Medullary,  737. 
Meiano-carcinomata,  7G3. 

Melanoma,  melanosis,  663,  720 ;  benignant,  684. 
Meliceris,  755. 
Mercury  in  syphilis,  473. 
Metastatic  abscesses,  393  ;   inflammations,    411 ; 

meningitis,  411 ;  tumors,  071. 
Methyline,  20. 
Miasm,  302,  419. 
Micrococcus,  182.  372,  877,  472. 
Miliary  tubercles  in  bones,  511. 
Militarv  surgeons,  273. 
Milzbrand,  434. 
Mineral  waters,  471. 
Mitella,  217. 
Moist  gangrene,  353. 
Moist  warmth,  187,  474. 
Moles,  684. 

Molluscum  contagiosum,  670;  m.  flbrosum.  684. 
Mimas  tuberculosum,  46ii. 
Morbus   Brightii,  cause  of  gangrene,  861 ;    with 

caries,  52ii. 
Mortification,  353. 
Morve,  433. 
Mother's  marks,  684. 
Mother  of  pearl.  334. 
Mouth  and  boof  disease,  436. 
Moxa,  477. 

54 


Mucous  bursso,  inflammation  of,  320. 

"  "      fistula;  of,  585. 

Mucous  membram-s,  inflammation  of,  310,  581. 
Mucous  salivary  diphtheria,  871. 
Mucous  tissue,  71S. 
Mud-baths.  479. 
Multiplying  pulleys,  264. 
Mummification.  353. 
Mures  articularcs,  598. 
Muscles,   inflammation  of,   319;    contraction  of^ 

619;  rupture  of,  191 ;  artificial,  631. 
Muscular  contractions,  619. 
Myelitis  spinalis,  425. 
Myeloid  tumor,  730. 
Myoma,  704 ;  laavicellulare,  685. 
Myosin,  80. 
Myositis,  319. 
Myotomy,  624. 
Myxoma,  719. 

Naevus,  700 ;  vasculosus,  714. 

Nares,  plugging,  34. 

Nasal  polypi,  6»8. 

Necrosis,"  168,  226,  529;    diagnosis  from  caries, 

544 ;  induced,  531 ;  from  phosphorus,  539. 
Needle-holder,  47. 

Needles,  surgical,  45, 138;  as  foreign  bodies,  138. 
Nephritis,  metastatic,  412. 
Nerves,  regeneration  of,  422,  725;  compression 

of,  150. 
Neuromata,  126,  688,  705. 
Neuropaths,  301. 
Noma,  361. 
Nose,  cancer  of,  787. 
Nulltour,  48. 

Occlusion  of  wonnd.s.  108. 
Ocular  muscles,  tenotomy  of,  027. 
Ccuhsts,  9. 
Odontoma,  699. 
CEdema,  19. 

(Esophagus,  stricture  of,  624. 
Oil  of  turpentine,  39. 
Oil  poured  in  wounds,  280. 
Omartbrose,  5t2. 
Oucotomy,  319. 
Onkology,  662. 
Open  fractures,  222. 
Opium,  427. 
Orthopedy,  623. 
Osseous  granulations,  227. 
Os.sium  sclerosis,  50:5 ;  Icont.asis,  508. 
Osteocopic  pains,  497. 
Osteoid  chondroma,  696. 
Osteoma,  698. 
Osteomalacia,  196,  515,  550. 
Osteomyelitis,  325.  530,  807. 
Osteophlebitis,  327. 
Osteophytes.  282.  496,  .'S99. 
Osteoplastic  periostitis  and  ostitis,  496. 
Osteoporosis,  551. 
Osteosarcoma,  730. 
Osteotomy,  247,  012. 

Ostitis,  241,  331,  580;  fungo.sa,  502;   gimimosa, 
504;  interna.  505:  rarefying.  505;  vascular,  502. 
Ovary,  cysts  of,  758;  cancer,  791. 

Padua  school,  7. 

P.ain,  10.  450. 

Panaritium.  812,  821 ;  periostale,  330. 

Pap-bags,  753. 

Papillary  prolifer.ations,  C63. 

Papil  Ionia.  7-18. 

Paquelin's  cautery,  84. 

Paraglobulin,  80. 

I'aralysis.  620. 

I'araphimosis  3,56. 

Parasites,  cystic^  750. 

Paronychia.  812. 

Pavia  school,  7. 


834 


INDEX. 


Pearl  tumors,  721,  755. 

Pectus  carinatum,  547. 

Pelvis,  chondroma  of,  C96. 

Penghawar  Djamba,  34. 

Periadenitis,  389. 

Periosteum,  324. 

Periostitis,  3-25,  495,  530 ;  cteoplastic,  496 ;  sup- 
purative. -I'i'^. 

Peripsoitis,  C19. 

Perlsucht.  46o. 

Permanent  extension,  21G. 

I'erniones,  29>-. 

Pes  planus,  618  ;  varus.  CIS. 

Peyor's  plands,  liypei trophy  of,  743. 

Pharynx,  chronic  catarrh  of,  742. 

Phlebitis.  179,  3bii,  89U. 

Phlebolitbes.  6-36. 

Phleg-monous  inflammation,  312. 

Phlogogenous.  99. 

Phos|)horus,  243. 

Phosphorus-poisoning,  539. 

Pin  in  vesical  calculus,  139. 

PitjTiasis  ver.-icolor,  4'  2. 

Master,  41;  adhesive,  42;  ichthyocoUa, 48 ;  splints, 
213.  2S4. 

Plaster  of  Paris  bandage,  213. 

Pleuritls,  411. 

Pleuro-pneumonia,  43T. 

Podagra,  470. 

Pcedartbrocacc.  618. 

I  oisoncd  wounds,  430. 

Polypus,  Gt>!;  aural,  747-  cystic,  758;  mucous, 
747 ;  nasal.  74  ^ ;  nasopnaryngcal,  6 jS  ;  rectal, 
747 ;  uterine.  OsS,  74S. 

roiiJicJ^'-f  method  of  transfusion,  290. 

Porcupine-disease.  745. 

Posterior  nar^'.s.  plugging,  85. 

Pott's  bo.ss,  513. 

Pourritiire  des  hi'spitaux,  869. 

Pressure  for  cure  of  cicatrices,  624 

Prostate,  hypertrophy  of,  746;  cancer  of,  746,  790. 

Protagon,  8ii. 

Provisional  dressing.  216. 
'■  callus,  2t2. 

Psammona,  721. 

Fscudarthrosis.  208.  241. 

Pseudo-erysipelas,Jii2. 

Pseudo-lcucoeiiiia.  739. 

Psoitis.  619. 

Puerperal  fever,  406, 423 ;  inflammation  of  joints, 
;;43. 

Pulse  in  inflammation,  95. 

i  ubionssysicm,  421. 

Punctured  wour.ds.  loS;  of  arteries,  142;  of  cav- 
ities. 142;  of  nerves,  142  ;  of  veins,  147. 

Punk,  39. 

Purpura.  153. 

Purulent  infection,  pyaemia,  408. 
'•       infiltration,  315. 

Pus,  76,  r.U;  injected  into  the  blood,  9S. 
"    disease,  79,  408. 

Pustula  maligna,  434. 

Putrid  fever.  1S3. 

"      matter  injected  into  the  blood,  403. 

P3-aE'raia,  343,  101,  408;  in  newly -born,  844; 
spontaneous,  420. 

Pyohaemia,  415. 

Pyrogenous,  98. 

Quinine,  422. 

P.a-ihitic  rose-gar" and,  547. 

Rachitis.  .'> '5. 

Kag-diseise.  ■'42. 

Railro.ad  injuries,  163. 

Eannla,  753. 

Paph.nnia.  361. 

Paspatorium,  544. 

Pe.ibsorption  of  f'ead  bone,  2':7,  245. 

Eectum,  cancer  of,  733. 


Eecurrence  of  tumors,  079. 

Eed  blood-cells,  escape  of,  through  -walls  of  ves- 
sels, 445. 

Redness,  450. 

Resection,  818;  of  fragments,  2-14,  284;  for  Jin- 
chylosis,  612;  of  ankle,  oTJ;  of  elbow,  572  ;  of 
hip,  572:  of  joints,  571;  cf  knee,  57'!;  pcrtial, 
52s;  of  shoulder,  573 ;  total,  269;  of  wrist,  174. 

Resolvents,  475. 

Rest,  474. 

Rheumatism,  840,  5r2 ;  gonorrhcccl,  012. 

Rheuin.itie  gout.  5  2. 

Rheumatismus  nodosus,  592. 

i:higol:ne,  20. 

Rickets.  I'.ifi. 

Ruptures  of  muscles,  ICl. 

Salamanca  school,  7. 

Salamauders,  J26. 

Salivary  glands,  adenoma  of,  735. 

Salt-w,ater  baths,  46. 

Sand-bags,  217. 

Sarcoma,  714  ;  alveolar,  719  ;  gelatinous,  710  ; 
piant-eellod.  717;  granulation,  glio-,  'il5;  fas- 
ciculate, 726;  mucous,  7lv;  mammary,  7tl ; 
melanotic,  720;  ossification  of,  726 ;  pifrmentary, 
721);  net-celled,  719;  spindle-celled,  7 15. 

Sarcomatous  papillomata,  773. 

Scalds.  286. 

Schneider-MetiePH  apparatus,  264. 

Scirrhus,  75s ;  mamma',  7b4. 

Sclerosis  ossium,  508. 

Scoliosis,  617. 

Scorbutus.  471. 

Scorpion,  401,  440. 

Scrofula,  45.5. 

Sebaceous  glands,  cysts  of,  752. 

Secondary  inflammation  of  suppurating  womido, 
170. 

Secondary  or  suppurative  fever,  163. 

Scpsin,  403. 

Scptica-mia,  173,  402. 

Sequestrotomv,  548. 

Sequestrum.  226.  >'i29,  C43. 

Serous  transudation,  S51. 

Seton,  244,  477. 

Shock,  167. 

Silk,  44, 

Siren,  615,  C31. 

Skin-grafting,  103. 

Slings,  217 

Snake-bites.  481. 

SnuflBes,  301. 

Spedalsked,  6s.5. 

Sphacelus,  558. 

Spina  ventosa,  518. 

Spleen,  hypertrophy  of.  787;  in  pyaemia.  804. 

Splints,  plaster  ot  Paris,  213  ;  dextrine,  wbite-of- 
epg,  paste.  215;  gutta-percha,  215;  liquid-glass, 
215 ;  starch,  215. 

Spongy  bones,  inflammation  of,  £30. 

Sprain,  2i"(0. 

Spurred  rye.  sccale  cornutum,  860. 

Squirrhe  piistiileux.  7&7. 

Starch-dressings.  215. 

Sterno-clcido-mastoid  muscle,  division  of,  C27. 

Stiff  joints,  556. 

Stigmata,  67,  846. 

Stings  of  insects.  430. 

Stomach,  cancer  of.  7S9. 

Strabismus,  operation  for.  627. 

Struma,  C68 :  aneurysmatica,  750 ;  cystica,  748. 

Stumps,  conical,  S14. 

Stvptics,  8H. 

Subcutaneous  operations  142,  244,  247. 

Subluxation,  260. 

Sugar  in  urine.  809. 

Suggillati.ns.  153. 

Sulphurets  of  the  alkalies,  <2S. 

Sunburn,  sun  troke,  292. 


INDEX. 


835 


Suppuration,  156;  blue,  -146. 

Suppurative  fever,  408. 

Surgeon  s  knot,  28. 

Surirical  needles.  45. 

Sutures,  44;  of  bone.  244;  catgut,  horseliair.  46- 

interrupted,  4G;  twisted.  48.  '       ' 

Swedish  movement-cure,  630. 
Swelling  in  inflammation,  450. 
Synovia,  escape  of,  252. 
Synovial  hernia,  581 ;  membrane,  559. 
Synovitis,   254;    parenchymatous,   336;    chronic 

serous,  554,  578,  587. 
Syphilis,  471. 
Syphiloma,  472. 

Tadpoles,  regeneration  of,  126. 

Tampon,  36. 

'lappiug  the  joints.  530. 

Tarantula,  4'31. 

Tartar-emetic  ointment.  476. 

Teeth,  reimplantation  of,  74. 

Telangiec  asis,  663,  706. 

Temperature  in  disease.  95. 

Tendons,  affections  of  sheaths  of,  320,  581 ;  luxa- 
tions of,  270. 

Tenotomy,  6j4. 

Tetanus,  trismus,  142,  424. 

'r 'edeii'a  dressing,  38. 

Thermometer  in  disease.  95. 

Thrombosis,  147,  347,  357,  386. 

Thrombus,  127. 

Thymus  gland,  hypertrophv  of,  743. 

Thyroid  gland,  adenoma  of  757 :  cyst  of,  758  ; 
cancer,  791  ;  tumors  of,  748. 

Tibi.a,  fibromata  on.  688. 

Tincture  iodinii.  476. 

Tissu  flbroplastique,  716;  hetjroadenique,  762. 

Tonsils,  hypertrophy  of,  742. 

Tourniquet,  32. 

Transfusion.  41 . 

Transplantation  of  cancer-germs,  o71,  774. 

Traumatic  fever.  95,  3'.i?. 
"        tetanus,  142. 

Trichinje,  751 

Tiipolilh,  219. 

Trocar,  138. 

Tubercubsis,  453,  487. 

Tumor  aibus,  44.5,  555. 

Tumors.  655;  benign.  664;  caneeroua,  677;  car- 
tilage, 682;  of  brain,  663;  contagiousness  of, 
672;  fatty,  692;  infectious,  678;  malignant, 
metastatic,  671 ;  multiple,  678;  secondary,  671 ; 
vascular,  708. 

Turning  the  foot,  250. 


Turpentine  for  hiemorrhage,  39. 
Typhous  diseas'-R  418 
Tyrosin,  80. 

rricer,  480 ;  atonic,  483 ;  catarrhal,  482 ;  callous 
4.^0;  erethitic,  485;  fungous,  466;  fistulous" 
sinuous.  488;  lupous,  490;  open.  4^0;  ph.nf;c" 
denic.  488;  proliferating.  483;  scorlmtic.  -^'j  ; 
scrofulous,  490;  suppurating,  488:  syminomat- 
ic,  489;  syphilitic,  492;  typhous.  4Si:;  varicose, 
489. 

Ulceration,  354. 

Uncipressure,  33. 

Urethral  caruncles,  749. 

Ut't'rine  lymphangitis,  379 ;  cancer,  790. 

Vaccination  of  angioma,  711. 

VaUiilra's  treatment  of  aneurism,  643. 
Varices,  634. 
Varicose  ulcer,  4>-9. 
Vari.x  aneurysmaticus,  146,  636. 
Vascular  tumors,  7il6. 
Vein-stones.  636. 

Veins,  varicose.  fSo:  injection  of  ammonia  into, 
431 ;   injured  in  open  fractures,  224 ;   woundb 
of.  147. 
Venesection,  22,  147. 
Ventilation.  421. 
Veratria,  429. 
Vesical  cancer.  763. 
Vessels,  formation  of,  70. 
Vibices,  15;i. 
Villous  cancer,  774. 
Vipera,  431. 

Virus,  cultivation  of,  404. 
Vitelline  spheres,  659. 

Volkmann's  dressing,  105,  220. 

Wandering  cells,  61,  65,  656. 

Warts,  744. 

Water-bath,  174  ;  bed,  291 ;  canker,  861. 

White-of-egg,  215. 

"  Wind  of  the  ball,"  275. 

Wire  sutures,  46. 

Wound-douche.  E.smarc.h\o,  102. 

Wounded  pet.sons,  care  of,  94. 

Wounds,  contused.  163;  croup  o^  118;  diph- 
theria of,  US;  fistulous,  107;  direct  union  of, 
II.t;  flap,  18;  incised,  17,  101;  gunshot,  278; 
lacer.ated,  191;  penetrating,  IS;  poisoned,  480; 
puncture,  138. 

Zoonoses,  443. 


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A  PRACTICAL  TREATISE  ON  THE  SURGICAL 

DISEASES    OF   THE    GENITO-URINARY 

ORGANS,  INCLUDING  SYPHILIS. 

Designed  as  a  Manual  for  Students  and  Practitionerji.  With  Engravings  and 
Cases.  By  W.  H.  Van  Buren,  A.  M.,  M.  D.,  late  Professor  of  Princlj)lc3 
of  Surgery,  with  Diseases  of  the  Genito-Urinary  System  and  Clinical  Surgery, 
in  Bellevue  Hospital  Medical  College,  etc.,  and  E.  L.  Keyes,  A.M.,  M.  D., 
Professor  of  Dermatology  in  Bellevue  Hospital  Medical  College;  Surgeon 
to  the  Charity  Hospital,  Venereal  Diseases,  etc. 


One  volume,  8vo,  6*72  pages.     Cloth,  $5.00 ;  sheep,  .$6.00. 


This  work  is  really  a  compendium  of,  and  a  book  of  reference  to,  all  modern  works 
treating  in  any  way  of  the  surgical  diseases  of  the  genito-urinary  organs.  At  the  same 
time,  no  other  single  book  contains  so  large  an  array  of  original  facts  concerning  the 
class  of  diseases  with  which  it  deals.  These  facts  are  largely  drawn  from  the  extensive 
and  varied  experience  of  the  authors. 

Many  important  branches  of  genito-urinary  diseases,  as  the  cutaneous  maladies  of 
the  penis  and  scrotum,  receive  a  thorough  and  exhaustive  treatment  that  the  profcs.-^ional 
realer  will  search  for  elsewhere  in  vain. 

The  subject  of  .syphilis  is  included,  of  necessity,  in  this  treatise.  Although  properly 
belonging  to  the  department  of  Principles  of  Surgery,  there  is  no  disease  falling  within 
the  limits  of  this  work  concerning  which  clear  and  correct  ideas  as  to  nature  and  treat- 
ment will,  at  the  present  time,  so  seriously  influence  success  in  practice. 

The  work  is  elegantly  and  profusely  illustrated,  and  enriched  by  fifty-five  original 
cases,  setting  forth  obscure  and  difficult  points  in  diagnosis  and  treatment. 


New  York :  D.  APPLETON  &  CO.,    1,  8,  &  5  Bond  Street. 


NOW  READY,  A  NEW  EDITION  OF 

LECTURES  0?f  ORTHOPEDIC  SUR- 

GEEY  AND  DISEASES  OF  THE  JOINTS. 

By  LEWIS  A.  SAYRE,  M.  D., 
Professor  of  Orthopedic  Surgery  and  Clinical  Surgery  in  Bellevue  Hospital  Medical  Col- 
lege ;  Consulting  Surgeon  to  Bellevue  Hospital,  Charity  Hospital,  St.  Elizabeth's 
Hospital,  Northwestern  Dispensary,  etc.,  etc. 

Illustrated  with  324  Engravings  on  Wood.     1  vol.,  8vo.     Cloth,  $6.00 ;  sheep,  §6.00. 

"  This  edition  has  been  thoroughly  revised  and  rearranged,  and  the  subjects 
classified  in  the  anatomical  and  pathological  order  of  their  development.  Many 
of  the  chapters  have  been  entirely  rewritten,  and  several  new  ones  added,  and 
the  whole  work  brought  up  to  the  present  time,  with  all  the  new  improvements 
that  have  been  developed  in  this  department  of  surgery.  Many  new  engravings 
have  been  added,  each  illusti-ating  some  special  point  in  practice." — Author. 

NOTICES  OF  FORMER  EDITIONS. 

"  The  name  of  the  author  is  a  sufficient  guarantee  of  its  excellence,  as  no  man  in 
America  or  elsewhere  has  devoted  such  unremitting  attention  for  the  past  thirty  years  to 
this  department  of  surgery,  or  given  to  the  profession  so  many  new  truths  and  laws  as 
applying  to  the  pathology  and  treatment  of  deformities." —  Wcstei-n  Lancet. 

"  Dr.  Sayrc  has  stamped  his  individuality  on  every  part  of  his  book.  Possessed  of  a 
taste  for  mechanics,  he  has  admirably  utilized  it  in  so  modifying  the  inventions  of  others 
as  to  make  them  of  far  greater  practical  value.  The  care,  patience,  and  perseverance 
which  he  exhibits  in  fultilling  all  the  conditions  necessary  for  success  in  the  treatment 
of  this  troublesome  class  of  cases  are  worthy  of  all  praise  and  imitation." — Detroit  Review 
of  Aledicinc. 

"  Its  teaching  is  sound,  and  the  originality  throughout  very  pleasing ;  in  a  word,  no 
man  should  attempt  the  treatment  of  deformities  of  joint  affections  without  being  familiar 
with  the  views  contained  in  these  lectures." — Ceinada  Medical  and  Surgical  Journal. 


RECENTLY  ISSUED,  A  NEW  EDITION  OF 

A  PRACTICAL   MANUAL   ON  THE 

TREATMENT  OF  CLUB-FOOT. 

Fourth  edition.     Enlarged  and  corrected. 

By  LEWIS  A.  SAYRE,  M.  D., 

Professor  of  Orthopedic  Surgery  in  Bellevue  Hospital  Jlcdical  College ;  Surgeon  to  Belle- 
vue and  Charity  Hospitals,  etc. 

1  vol.,  12mo.     Illustrated.     Cloth,  $1.25. 

"  The  object  of  this  work  is  to  convey,  in  as  concise  a  manner  as  possible,  all 
the  practical  information  and  instruction  necessary  to  enable  the  general  practi- 
tioner to  apply  that  plan  of  treatment  which  has  been  so  successful  in  my  own 
hands." — Preface. 

"  The  book  will  very  well  satisfy  the  wants  of  the  majority  of  general  practitioners, 
for  whose  use,  as  stated,  it  is  intended." — New  York  Medical  journal. 


New  York :   D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


November,  1888. 

MEDICAL 

AND 

HYGIENIC    WOP.KS 


PUBLISHED    BY 


D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street,  New  York. 


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the  Practitioner.     Third  edition.     8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  Materia  Medica  and  Therapeutics. 
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BARTHOLOW  (ROBERTS).  A  Treatise  on  the  Practice  of  Medicine,  for  the 
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BARTHOLOW  (ROBERTS),  On  the  Antagonisiii  between  Medicines  and  be- 
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BILLROTH  (TIIEODOR).  General  Surgical  Patiiology  and  Therapeutics.  A 
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3 

BUCK  (GURDON).  Contributions  to  Reparative  Surgery,  shoWing  its  Applica- 
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Injui-y ;  Congenital  Defects  from  Arrest  or  Excess  of  Development;  and 
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CAMPBELL  (F.  R.).  The  Language  of  Medicine.  A  Manual  giving  the  Origin, 
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Medical  Literature.     8vo.     Cloth,  $3.00. 

CARPENTER  (W.  B.).  Principles  of  Mental  Physiology,  with  their  Applica- 
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Conditions.     12mo.     Cloth,  $3.00. 

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CORNING  (J.  L.).  Brain  Exhaustion,  with  some  Preliminary  Considerations 
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CORNING  (J.  L.).  Local  Anaesthesia  in  General  Medicine  and  Surgery.  Being 
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trations.    Small  8vo.     Cloth,  $1.25. 

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EVANS  (GEORGE  A.).  Iland-Book  of  Historical  anJ  Geographical  Phthisi- 
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United  States.     8vo.     Cloth,  $2.00. 

E  VETZKY  (ETIENNE).  The  Physiological  and  Therapeutical  Action  of  Ergot. 
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lated from  the  fourth  German  edition  by  Artliur  E.  J.  Barker,  M.  I).,  and 
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1887. 

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edition,  rewritten,  enlarged,  and  improved.    8vo.    Cloth,  $5.00;  sheep,  $6.00. 

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HAMMOND  (W.  A.).  Clinical  Lectures  on  Diseases  of  the  Nervous  System, 
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M.  D.     8vo.     Cloth,  $3.50. 

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Vienna.     Second  enlarged  and  improved  edition.     8vo.     Cloth,  $2.00. 

HOWE  (JOSEPH  W.).  Emergencies,  and  how  to  treat  them.  Fourth  edition, 
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HUXLEY  (T.  H.).  The  Anatomy  of  Vertebrated  Animals.  Hlustrated.  12mo. 
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JONES  (H.  MACNAUGHTON).  Practical  Manual  of  Diseases  of  Women  and 
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KEYES  (E.  L.).  A  Practical  Treatise  on  Genito-Urinary  Diseases,  including 
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and  Keyes.  Almost  entirely  rewritten.  8vo.  With  Illustrations.  Cloth, 
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KEYES  (E.  L.).  The  Tonic  Treatment  of  Syphilis,  including  Local  Treatment 
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LORING  (EDWARD  G.).  A  Text-Book  of  Ophthalmoscopy.  Part  I.  The 
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131  Illustrations,  and  4  Chromo-Lithographs.     8vo.     Cloth,  $5.00. 

LUSK  (WILLIAM  T.).  The  Science  and  Art  of  Midwifery.  With  246  Illustra- 
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LUYS  (J.).  The  Brain  and  its  Functions.  With  Illustrations.  12mo.  Cloth, 
$1.50. 

MARKOE  (T.  M.).  A  Treatise  on  Diseases  of  the  Bones.  Witii  Illustrations. 
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MAUDSLEY  (HENRY).  Body  and  Mind  :  an  Inquiry  into  tlieir  Connection 
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8 

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